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Third heart sounds, which are low-pitched, early diastolic sounds best heard at the lower left sternal border, or apex, are frequently heard in children and are normal. They reflect rapid ventricular filling.

Fourth heart sounds, which are not often heard in children, are low-frequency, Fourth heart sounds represent delate diastolic sounds, occurring just before the first heart sound. creased ventricular compliance and are associated with congestive heart failure.

An apparent gallop, in the presence of a normal heart rate and rhythm, is a A gallop rhythm—tachycardia plus frequent finding in normal children and does not represent pathology. a loud third and/or fourth heart sound—is pathologic and indicates congestive heart failure and poor ventricular function.

One of the most challenging aspects to the cardiac examination in children is the evaluation of heart murmurs. In addition to the task of trying to listen to a squirming, perhaps uncooperative child, a major challenge is to distinguish common benign murmurs from unusual or pathologic ones. Heart murmurs in children must be characterized by specific location (e.g., left upper sternal border, not just left sternal border), timing, intensity, and quality. If each murmur is delineated that completely, the diagnosis is usually made, and all that is needed is confirmation and amplification with laboratory tools such as ECG, chest x-ray, and echocardiography.

An important rule of thumb is that, by definition, benign murmurs in children have no associated abnormal findings. Many (but not all) children with serious cardiac malformations have signs and symptoms other than a heart murmur obtainable on careful history or examination. Many will also have other, noncardiac signs and symptoms as well, including evidence of genetic defects that may offer helpful diagnostic clues.

The presence of any of the non-cardiac findings that frequently accompany cardiac disease in children markedly raises the possibility that a murmur that appears benign is really pathologic.

Most children (indeed, some say nearly all) will have one or more functional, or benign, heart murmur before reaching adulthood. It is important to identify functional murmurs by their specific qualities rather than by their softness. The common functional murmurs of infancy and childhood should be easily recognized by the practitioner and under most circumstances do not require evaluation.

The figure on the next page characterizes benign heart murmurs of children according to their location, key characteristics, and typical ages of presentation. These benign murmurs may be noted as children age:

Many pathologic murmurs of congenital heart disease are present at birth. Others are not apparent until later, depending on their severity, drop in pulmonary vascular resistance following birth, or changes associated with growth of the child. Table 17-16 on pp. 773-775 shows examples of pathologic murmurs of childhood.

Neonates

Closing ductus murmur

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