The paediatriccardiovascularexam can be a logistical minefield, requiring a good understanding of cardiac anatomy and possible congenital anomalies. With babies especially, it’s important to be opportunistic with your examination – doing the three ‘quiet things’ first: auscultation of heart sounds, auscultation of breath sounds and palpation of femoral pulses.
With all children, don’t expect to follow a pre-defined order. Be creative and playful, making the examination into a game involving parents, siblings and the toys available to you.
4. Pacemaker or implantable cardioverter-defibrillator scar
5. Chest drain scars
Start with the abdomen and then work up to the chest. If appropriate, ask the child what they ate for their last meal and try to ‘find it’. If you can’t ‘find it’, you’ll have to listen – leading you to auscultation (sneaky right?).
In a healthy child, the liveredge may be palpated up to 2cm below the costal margin. If the liver edge is more prominent, it would suggest the presence of hepatomegaly. Heart failure is a potential cause of hepatomegaly.
1. Begin palpation in the right iliac fossa using the flat edge of your hand (radial side of your right index finger)
2. Press your hand into the abdomen as the child breathes in
3. Feel for a step, as the liver edge passes below your hand
4. If you don’t feel anything, repeat the process with your hand 1-2 cm higher
If you feel the liver edge, note the following:
The degree of extension below the costal margin
The consistency of the liver edge (smooth/irregular)
Tenderness – suggestive of hepatitis
Pulsatility – a pulsatile enlarged liver can be caused by tricuspid regurgitation
If hepatomegaly is present, you should also assess for splenomegaly. See the paediatricabdominalexamination guide for details on how to perform splenic palpation.
Palpate the apex beat
Palpate the cardiac apex, noting its position.
<7 years old: 4th intercostal space, to the left of the midclavicular line
>7 years old: 5th intercostal space, midclavicular line
Left displacement – cardiomegaly, pectus excavatum, scoliosis
Right displacement – dextrocardia, left diaphragmatic hernia, collapsed lung on right, left pleural effusion, left pneumothorax
Assess for heaves and thrills
A parasternalheave is a precordial impulse that can be palpated
Parasternal heaves are present in patients with rightventricularhypertrophy
Place the heel of yourhand parallel to the leftsternaledge (fingers vertical) to palpate for heaves
If heaves are present you should feel the heel of your hand being lifted with each systole
Tip: Instead of the heel of your hand, use your fingertips with babies and younger children
A thrill is a palpablevibration caused by turbulentbloodflow through a heartvalve (the thrill is a palpable murmur)
You should assess for a thrill across each of the heartvalves in turn
To do this place your hand horizontally across the chestwall, with the flats of your fingers and palm over the valve to be assessed
Auscultate the heart
Start by showing the child your stethoscope and demonstrate it on your own chest and/or on one of their toys to familiarise them with this piece of equipment.
Suggest listening to their chest, making sure the stethoscope diaphragm isn’t cold prior to it making contact with the child.
Tip: Play a game to see who can stay quiet the longest – involve the parents!
Areas of the heart to auscultate
Auscultate ‘upwards’ through the valve areas using the diaphragm of the stethoscope:
Mitral valve – 5th intercostal space – midclavicular line (apex beat)
Tricuspid valve– 4th or 5th intercostal space – lower left sternal edge
Pulmonary valve– 2nd intercostal space – left sternal edge
Aortic valve– 2nd intercostal space – right sternal edge
Listen over each area with both the bell (for low pitched sounds – gallops and split S2) and the diaphragm (high pitched sounds – pericardial rubs, S1/S2 and most murmurs).
Tip: Complex cardiac anomalies may cause you to hear multiple dynamic murmurs (e.g. Tetralogy of Fallot)
Auscultate the lungs
Ask the child to take ‘big breaths’ – some abnormal sounds may be inaudible if taking shallow breaths
Auscultate each side of the chest in a symmetrical pattern, comparingside to side
Pay attention to the inspiratory and expiratory sounds at each placement
Note the quality and volume of breathsounds
Note any additional sounds
Repeatauscultation on the posterior aspect of the chest
Coarse bibasal crackles may be a late sign of pulmonary congestion secondary to congestive heart failure.
To Complete the Examination…
Assess for oedema
Ask the parents if the child looks puffy or swollen.
Inspect the limbs, sacral area and face – affected areas will depend on the age of the child and mobility status.
Peripheral oedema often occurs in right-sided heart failure.
Ensure the child is re-dressed after the examination
Thank the child and/or parents
Explain your findings to the parents and/or child
Ask if the parents and/or child have any questions
More than 50% of children will have a murmur at some point while congenital heart disease is present in less than 1% of children. The table below includes a non-exhaustive list of murmur characteristics and underlying causes.
Aortic area – aortic stenosis
Ejection systolic with fixed P2 – atrial septal defect;
Ejection systolic without fixed P2 – pulmonary stenosis (radiates to axilla/back, louder on inspiration)