Ii

I II

Transient, soft, ejection Upper left sternal border

Soft, slightly ejectile, systolic To left of upper left sternal border and in lung fields and axillae

Grade I-II/VI, musical, vibratory Multiple overtones Early and midsystolic Mid/lower left sternal border Frequently also a carotid bruit

Soft, hollow, continuous Louder in diastole Under clavicle

Can be eliminated by maneuvers

Early and midsystolic Usually louder on left Eliminated by carotid compression

Grade I-II/VI soft, nonharsh Ejection in timing Upper left sternal border Normal P2

The neonate may have a transient, soft, ejection murmur at the upper left sternal border and to the left, as flow continues through a closing ductus arteriosus. This murmur usually disappears within a day or two after birth.

A pathologic patent ductus arteriosus transmits a continuous murmur at the upper left sternal border of neonates, and is frequently accompanied by a loud P2, bounding pulses, and developing congestive heart failure.

A pulmonary flow murmur in the newborn who has signs of other disease is more likely to be pathologic. Diseases may include Williams syndrome, congenital rubella syndrome, and Alagille syndrome.

Preschool and school-aged children often have benign murmurs. The most common (Still's murmur) is a grade I-II/VI, musical, vibratory, early and midsystolic murmur with multiple overtones, located over the mid or lower left sternal border, but also frequently heard over the carotid arteries. Carotid artery compression will usually cause the precordial murmur to disappear. This murmur may be extremely variable and may be accentuated when cardiac output is increased, as occurs with fever or exercise.

The murmur heard in the carotid area or just above the clavicles is known as a carotid bruit. It is early and midsystolic, with a slightly harsh quality. It is usually louder on the left and may be heard alone or in combination with the Still's murmur, as noted above. It may be completely eradicated by carotid artery compression.

Some neonates and infants will have a soft, somewhat ejectile murmur heard, not over the precordium, but over the lung fields, particularly in the axillae. This represents peripheral pulmonary artery flow and is partly the result of inadequate pulmonary artery growth in utero (when there is little pulmonary blood flow) and the sharp angle at which the pulmonary artery curves backward. In the absence of any physical findings to suggest additional underlying diseases, this peripheral pulmonary flow murmur can be considered benign and usually disappears by the age of 1 year.

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