With Cardiac Disease

Poor feeding Tachypnea

Failure to thrive Hepatomegaly

Irritability Clubbing

A diffuse bulge outward of the left side of the chest suggests longstanding cardiomegaly.

While observing the respiratory pattern, note any abnormalities of the sternum as discussed on p. 686.

Observation of the respiratory rate and pattern is helpful in distinguishing the degree of illness and cardiac versus pulmonary diseases. An increase in respiratory effort is expected from pulmonary diseases, whereas in cardiac disease there may be tachypnea, but not increased work of breathing until congestive heart failure becomes significant.

Palpation. The major branches of the aorta can be assessed by evaluation of the peripheral pulses. All neonates should have an evaluation of all pulses at the time of their newborn examination. In neonates and infants, the brachial artery pulse in the antecubital fossa is easier to feel than the radial artery pulse at the wrist. Both temporal arteries should be felt just in front of the ear. It is important to feel the femoral pulses. They lie in the midline just below the inguinal crease, between the iliac crest and the symphysis pubis. Take your time and search for femoral pulses; they are difficult to detect in chubby, squirming infants. If you first flex the infant's thighs on the abdomen, this may overcome the reflex flexion that occurs when you then extend the legs. The dorsalis pedis and posterior tibial pulses in neonates and infants (see photo below) may be difficult to feel unless there is an abnormality involving aortic run-off. Normal pulses should have a sharp rise, be firm, and well localized.

The absence or diminution of femoral pulses is indicative of coarctation of the aorta. If you can't detect femoral pulses, measure blood pressures of the lower and upper extremities. If they are equal or lower in the legs, coarctation is likely to be present.

A weak or thready, diff ¡cult-to-feel, pulse may reflect myocardial dysfunction and congestive heart failure, particularly if associated with an unusual degree of tachycardia.

Although the pulses in the feet of neonates and infants are often faint, several conditions can cause full pulses, such as patent ductus arteriosus or truncus arteriosus.

As discussed on p. 658, carefully measure the blood pressure of infants and children as part of the cardiac examination. It may be helpful to measure the blood pressure in both arms and one leg at one time around age 3 to 4 years to check for possible coarctation of the aorta. Thereafter, only the right arm blood pressure needs to be measured.

The point of maximal impulse, or PMI, is not always palpable in infants and is affected by respiratory patterns, a full stomach, and the infant's positioning. It is usually an interspace higher than in adults during the first few years of life because the heart lies more horizontally within the chest.

Palpation of the chest wall will allow you to assess volume changes within the heart. For example, a hyperdynamic precordium reflects a big volume change.

Thrills are palpable when there is enough turbulence within the heart or great vessels to be transmitted to the surface. Knowledge of the structures beneath the precordium will allow you to determine the origin of the thrill. Thrills are easiest to feel with your palm or the base of your fingers, not your fingertips. Thrills have a somewhat rough, vibrating quality. The figure that follows shows locations of thrills from various cardiac abnormalities that occur in infants and children.

A "rolling" heave at the left sternal border suggests an increase in right ventricular work, while the same kind of motion closer to the apex suggests the same thing for the left ventricle.

Aortic valve stenosis

Pulmonary valve stenosis

Pulmonary valve stenosis

Severe right ventricular outflow tract obstruction at infundibular level, Tetralogy of Fallot

Ventricular septal defect

Auscultation. The heart rhythm is more easily evaluated in infants by listening to the heart than by feeling the peripheral pulses, but in older children can be done either way. Children commonly have a normal sinus dysrhythmia, with the heart rate increasing on inspiration and decreasing on expiration, sometimes quite abruptly. This is a normal finding and can be identified by its repetitive nature, its correlation with respiration, and by its involvement of several beats rather than a single beat.

Many children, particularly neonates, have premature atrial or ventricular beats that are often appreciated as "skipped" beats. They can usually be eradicated by increasing the intrinsic sinus rate by exercise, such as crying in an infant or jumping in an older child, although they may be more frequent in the postexercise period. In a completely healthy child, they are usually benign and rarely persist.

The Si and S2 heart sounds should be evaluated carefully. They are normally crisp. The second sounds (S2) at the base are usually heard separately but should fuse into a single sound in deep expiration. In the neonate, it should be possible to detect a split second sound if the infant is examined when completely quiet or asleep; detecting this split eliminates many, but not all, of the more serious congenital cardiac defects.

The most common dysrhythmia in children is paroxysmal supraventricular tachycardia, or paroxysmal atrial tachycardia (PSVT, or PAT). It can occur at any age, including in utero. It is remarkably well tolerated by some children and is found on examination when the child looks perfectly healthy, may be mildly pale or has tachypnea, but has a rapid, sustained, completely regular heart rate of 240 beats per minute or more. Other children, particularly neonates, appear very ill with this condition. In older children, this dysrhythmia is more likely to be truly paroxysmal, with episodes of varying duration and varying frequency (see Table 17-5, p. 758).

Pathologic arrhythmias in children can be due to structural cardiac lesions, but also to other causes such as drug ingestion, metabolic abnormalities, endocrine disorders, serious infections, and postinfectious states, or they may be related to conduction disturbances without structural heart disease.

Distant heart tones suggest pericardial effusion; mushy, less distinct heart sounds suggest myocardial dysfunction.

Characteristics of Normal Variants of Heart Rhythms in Children

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