Heart murmurs

For Emergency Departments, For General Practitioners,

 

With thanks to Dr Tom Waterfield for his work on this article as part of our series on the 6 week baby check…

The assessment of murmurs can be difficult and identification of the underlying pathology, if any, is best left to a specialist.  For the purpose of the 6 week screening test all murmurs should be referred for further assessment but it is important to identify those children that require urgent assessment from the vast majority that simply require re-assurance and routine referral to a general paediatrician or paediatric cardiologist.

A hypothetical model of heart murmurs in children aged 1 month to 18 years done by an NHS economic evaluation team (http://www.crd.york.ac.uk/CRDWeb/ShowRecord.asp?ID=22002001874) suggested that only approximately 2% of these murmurs would be due to an underlying structural anomaly.   I think the wide age range might undermine this statistic’s relevance to the 6 week check cohort of babies.  A more widely quoted reference from 1998 reports that of 50 healthy term babies with heart murmurs, in 64% the murmur had disappeared by 6 weeks of age.  None of the babies had clinically significant congenital heart disease  and had all disappeared by 6 months of age but one baby had developed a different innocent murmur!  Read the full text of this paper at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1720793/pdf/v078p0F166.pdf.

If a murmur is detected it is important to consider the likelihood of there being significant underlying disease before referring for further assessment and before discussing the murmur with the parents. 

Innocent murmurs are common in children and are associated with normal weight gain, normal feeding and an otherwise normal clinical examination. 

The key points of clinical assessment include:

1)      Assessment of the murmur

  1. Location on the precordium e.g. left sternal edge (Common site of innocent murmurs)
  2. Intensity (1/6 = almost inaudible, 3/6 = audible with a stethoscope, 6/6 easily audible without a stethoscope and associated with a palpable thrill).  Murmurs are more often described now as soft or loud, harsh or musical.
  3. Variability with position – a feature of innocent murmurs (but not something one necessarily notices at the 6/52 check)
  4. Diastolic Vs Systolic – diastolic murmurs should always be treated as pathological

2)      Assessment of perfusion

  1. A pink child with a capillary refill time <2 seconds and with good peripheral pulses (including femoral pulses) is less likely to have significant heart disease
  2. Absent femoral pulses may represent coarctation of the aorta
  3. Cyanotic heart lesions rarely present outside the immediate perinatal period 

3)      Assessment for signs of heart failure

  1. Failure to thrive and recurrent respiratory infections
  2. Respiratory distress with hepatomegaly.  Crackles are not really heard in heart failure in infants
  3. Peripheral oedema and a raised JVP are NOT features of heart failure in this age group and their absence is not reassuring

If a child has a soft systolic murmur at the 6 week check and is growing well and feeding normally with an otherwise normal examination the child can be referred routinely to paediatric outpatients and the parents reassured that the murmur is likely to be due to the normal flow of blood around the heart.  If there are any worrying features then the child should ideally be discussed with the paediatric registrar on call and the appropriate referral or admission discussed.

References

The British Heart Foundation has a factfile sheet for GPs on heart murmurs in children but it is not downloadable from http://www.bhf.org.uk because it is over 5 years old and they worry that their old factsheets may go out of date.  BHF have however very kindly sent it to me and allowed me to upload it on to this site as an educational resource.  Download it here.

http://www.patient.co.uk/doctor/Heart-Murmurs-in-Children.htm would be a good resource except that it still talks about antibiotics for children with heart defects when they have dental treatment and we gave up doing that in 2008 after NICE said it wasn’t necessary (http://www.nice.org.uk/nicemedia/live/11938/40014/40014.pdf).

http://www.tinytickers.org is a parental support website concerned primarily with antenatal diagnosis and screening.

http://kidshealth.org/parent/medical/heart/murmurs.html# is one of the top American sites on children’s health aimed at the general public.  It provides balanced information in clear English about heart murmurs for parents who are worried that their GP has picked up a heart murmur incidentally on examining their child.  Our outreach cardiologist has written a few words on innocent heart murmurs too at http://www.kidscardiologist.com/conditions/innocent-murmur.html.

If your patient does turn out to have congenital heart disease, http://www.rch.org.au/cardiology/defects.cfm?doc_id=3011 is a fantastic site from Melbourne’s Royal Children Hospital with lovely clear diagrams and explanations of different morphological anomalies.

Bronchiolitis season

For Emergency Departments, For General Practitioners, ,

 

With thanks to Amutha for this article….

As winter approaches, most of us are very well aware that the bronchiolitis season is in full swing. Bronchiolitis is a lower respiratory tract infection – in the under 1s predominantly – that can cause fever, dry cough, nasal discharge and bilateral fine inspiratory creps ± wheeze.  Most cases of bronchiolitis occur from November to March, when the viruses that can cause bronchiolitis are more common. It is also possible to get bronchiolitis more than once during the same winter season (1).

Treatment is largely supportive and many infants are managed at home if they are feeding adequately and do not have significant respiratory difficulty.  Patients at high risk are ex-premature babies, those with congenital cardiac or respiratory diseases, immunodeficiency and babies < 3months of age (2).  When seeing a child, we should focus our history and examination on risk factors, signs of dehydration and respiratory distress.  This podcast provides an example of respiratory distress:

 http://empem.org/2010/09/bronchiolitis-part-1-of-2/comment-page-1/#comment-294

 3% of children will present with severe illness and require admission (2).  Map of Medicine (http://healthguides.mapofmedicine.com/choices/map/bronchiolitis1.html)  defines “severe” as those with:

  • poor feeding – less than half normal intake
  • lethargy
  • history of apnoea
  • respiratory rate above 70breaths/minute
  • presence of nasal flare and/or grunting
  • severe chest wall recession
  • cyanosis
  • marked use of accessory muscles
  • marked intercostal and subcostal recession
  • oxygen saturation (SaO2) 94% or less

 There have been no therapies that have been consistently effective enough to change the current supportive management of bronchiolitis. The majority of trials show that bronchodilators do not provide benefit and their routine use is not recommended (3). 

 1.http://www.nhs.uk/conditions/Bronchiolitis/Pages/Introduction.aspx

 2. Scottish Intercollegiate Guidelines Network (SIGN). Bronchiolitis in children. A national clinical guideline. Edinburgh: SIGN; 2006. http://www.sign.ac.uk/pdf/sign91.pdf

3. Petruzella FD, Gorelick MH. Current therapies in bronchiolitis. Pediatr Emerg Care 2010 Apr;26(4):302-7

Local breastfeeding support

For General Practitioners

While doing the weekend ward round I came across this list of local breastfeeding support groups pinned up on the back of the neonatal unit door.  In the August GP Paediatric Pearls we wrote about tongue tie and feeding issues.  The volunteers listed here are the lactation counsellors that Mr Patel at Kings likes to assess the babies prior to referral to him for possible division of tongue tie.

Paediatric ECGs

For Emergency Departments

Paediatric ECGs take a bit of getting used to. They change with age and I always have a crib sheet with me if looking at them formally. Well, can any non-cardiologists remember off the top of their head how many little squares are allowed to make up the R wave in V1 in a 1 week old compared to what is normal in a 15 year old? I like the crib sheet from the university of Chicago available at http://learnpediatrics.com/body-systems/cardiology/approach-to-pediatric-ecg/ although the first test is to fill in the lead numbers on the last 2 pages as they seem to have been left off! I also use “How to read Paediatric ECGs” by Park and Guntheroth (Mosby Elsevier) although it probably has more detail than is necessary for non-paediatricians. October’s ED version of Paediatric Pearls provides this same link to the Chicago crib sheet and also refers the reader to a recent paper on cardiac arrythmias which has some nice illustrative ECG strips. For those of you interested in such things, there is a course on paediatric ECGs run by cardiology registrars in central London twice a year. Their website is www.paeds.co.uk/ecg and the next course is early November 2010.

Forthcoming child protection courses

Child Protection

All professionals who come into contact with children need Level 1 and 2 training.  You can do both levels on-line; register at www.e-lfh.org.uk where the safeguarding courses are listed under “Projects”. 

The Royal College of Paediatrics and Child Health holds a number of courses and advertises others, many of which are open to non-paediatricians.  Have a look at http://www.rcpch.ac.uk/Policy/Child-Protection/Child-Protection-Training. 

The Advanced Life Support Group also run child protection courses which have been developed with RCPCH.  More information about this on- line course from http://www.alsg.org/en/?q=en/cpip.

There is a very good course for paediatricians run at the Hillingdon Hospital twice a year on child protection and court skills.  They run in June and November each year.  See http://www.acpcltd.co.uk/hillingdon_cp_course.html.

Do let me know of any other courses using the Comments feature below.

Safeguarding resources

Child Protection, For Emergency Departments, For General Practitioners,

Please find local safeguarding boards contact details below.  Lots of information on what the LSCB is, training courses on offer, what to do if worried about a child, relevant local contact details etc.:

http://www.walthamforest.gov.uk/index/care/childrenandfamilies/childprotect/lscb.htm

http://www.redbridge.gov.uk/cms/benefits_care_and_health/children_and_families/protecting_and_safeguarding/safeguarding_children_board.aspx

Child Protection Handbook produced by Royal College of Paediatrics and Child Health (RCPCH) available to download in full from http://www.rcpch.ac.uk/Policy/Child-Protection/Child-Protection-Publications.  Do peruse the continually updated list of downloadable documents at this link.  For example the guidelines on when to suspect Fabricated and Induced Illness were updated in 2009 and quite substantially broadened.

NICE quick reference guideline on When to Suspect Child Maltreatment (July 2009) available at www.nice.org.uk/nicemedia/pdf/CG89QuickRefGuide.pdf

Working Together (2013) is a guide to inter-agency working to safeguard and promote the welfare of children https://www.gov.uk/government/publications/working-together-to-safeguard-children

In May 2010, after the election, the Department for Children, Schools and Families became the Department for Education.  The safeguarding content is currently split between the 2 websites.  Most of the Every Child Matters information is at www.dcsf.gov.uk/everychildmatters but some of the more up to date news on safeguarding issues is at http://www.education.gov.uk/childrenandyoungpeople/safeguardingandsocialworkreform.

A useful document on recognising physical abuse in children with fractures has just been published jointly by the NSPCC and Welsh Child Protection Systematic Review Group.  Compulsory reading for GPs and ED physicians I should think.  This Cardiff Core Info Group publish a number of excellent pamphlets on bites, head injury, burns, bruises and neglect.

Do use the comments box below to let me know about any other resources you would recommend.

Tinea capitis

For Emergency Departments, For General Practitioners

I saw a 4 year old lad in A and E last week and noticed incidentally that he had scalp ringworm.  Apparently his mum has been faithfully using an antifungal shampoo for 2 years and shaving his head intermittently but the scaliness and little spots keep coming back.  Hence featuring the management of tinea capitis in September’s Paediatric Pearls as a reminder.  Most of the infections in this area are caused by Tinea tonsurans, a dermatophyte which lives in the hair shaft and thus well protected from any shampoos people try to throw at it.  Treatment is systemic, not topical, and the only licensed treatment in children is oral griseofulvin.   There are a few new papers around documenting incidence and the different organisms that cause tinea but not much has changed from a management perspective since the 2000 guideline which is available in full from the British Association of Dermatologists’ website.  Don’t be put off by its being listed under “BAD guidelines”…    www.bad.org.uk/Portals/_Bad/Guidelines/Clinical%20Guidelines/Tinea%20Capitis.pdf