Murmurs — The majority of murmurs in infants and children are innocent murmurs, also referred to as functional murmurs. They are characterized by the following findings that usually differentiate them from pathologic murmurs:
?	Associated with quiet precordium
?	Associated with a normal second heart sound
?	Crescendo-decrescendo pattern
?	Intensity less than grade 3
?	Asymptomatic child

The most common functional murmur in infants is due to turbulence across the branch pulmonary arteries, which are not fully developed because of the relatively small amount of pulmonary blood flow in utero. It disappears typically by 6 months of age with the increase in size of the branch pulmonary arteries, resulting in a reduction in turbulence. It is characterized by a grade 1 to 2, medium to high-pitched midsystolic ejection murmur heard best at the upper left sternal border, which radiates to the axillae and back.

***When to REFER TO CARDS
Pathologic murmurs that are associated with specific cardiac defects include:
?	Pulmonic stenosis – Harsh systolic ejection murmur at the upper left sternal border
?	Aortic stenosis – Harsh systolic ejection murmur at the upper right sternal border
?	Ventricular septal defect – Harsh pansystolic murmur at the left sternal border
?	Patent ductus arteriosus (rarely coronary artery fistula or other collateral blood vessel) – Continuous murmur
?	Mitral regurgitation – Blowing, high-pitched systolic murmur at the apex

A more detailed discussion on the auscultation of cardiac murmurs is found separately. (See "Auscultation of cardiac murmurs".)
Second heart sound — Components of the second heart sound are best heard with the diaphragm of the stethoscope over the second left intercostal space, close to the sternal border. Abnormalities of the second heart sound are suggestive of underlying cardiac disease and include:
?	Widely split second heart sound is indicative of right ventricular volume overload, and is a common finding in patients with atrial septal defect. It may be hard to appreciate in infants and toddlers because of their faster heart rate and inability to cooperate in the examination.
?	Loud second heart sound is suggestive of pulmonary hypertension, which may be seen in several different congenital cardiac lesions.

Gallop — Gallop rhythm or constant third heart sound indicates serious heart disease. It may be the first indication of heart failure and is associated with cardiac disease characterized by ventricular dilatation, decreased systolic function, and elevated ventricular diastolic filling pressure. Gallops may be heard in patients with cardiomyopathy, atrio-ventricular incompetent valves, and left-to-right shunt disease.

Friction rub — Friction rub is an uncommon finding in children and, when present, suggests a diagnosis of pericarditis. It is characterized by a sandpaper-like sound that spans both systole and diastole with no relationship to other heart sounds. It may be accompanied by chest pain, and is usually associated with electrocardiography (ECG) abnormal findings of ST-T wave changes throughout all leads. (See "Etiology of pericardial disease".)

Peripheral pulses — As discussed previously, diminished peripheral pulses may be seen in patients with poor perfusion. (See 'Poor perfusion' above.)

In other circumstances, if only the pulses of the lower extremities are involved, the diagnosis of coarctation of the aorta needs to be considered. In these patients, four-extremity blood pressure measurement should be performed. If the systolic blood pressure in the legs is more than 10 mmHg lower than that measured in the arms, the patient should be referred to a pediatric cardiologist for further evaluation. (See "Clinical manifestations and diagnosis of coarctation of the aorta".)

Pulses may be diminished in the left arm in patients with an aberrant left subclavian artery, which may be a component of a vascular ring. Patients with a vascular ring may present with respiratory and/or gastrointestinal symptoms or be asymptomatic. (See "Vascular rings".)

Edema — Edema is not a common manifestation of cardiac disease in children, and is rare in infants with CHD. Although periorbital edema may be seen in patients with severe heart disease, it is rarely seen in isolation. Pedal and sacral edema are more commonly associated with renal disease, such as nephrotic syndrome. (See "Pathophysiology and etiology of edema in children".)

Hepatomegaly — An enlarged liver due to hepatic congestion can result from any cause of right-sided heart failure. The liver edge is typically firm and smooth.
Extracardiac abnormalities — Extracardiac abnormalities are frequently detected in children with CHD. Congenital skeletal abnormalities, especially those of the hand and arm, are often associated with cardiac malformations.
CHD may be a component of many specific syndromes and chromosomal disorders (table 3) [3]. For example, cardiac disease is seen in approximately one-half of individuals with Down syndrome. (See "Down syndrome: Clinical features and diagnosis", section on 'Heart disease'.)
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