What to do in the presence of a heart murmur in an asymptomatic child?

The detection of a heart murmur is an important problem faced by paediatricians in theirpractice and it is the most frequent reason for patient referral to cardiologists. The dilemma faced at such a time is to decide which child requires further evaluation and which child has an ?innocent? murmur. Up to 50% of children are detected to have a cardiac murmur. Some murmurs in neonates, many in infants and most in childhood are ?innocent?. Its detection implies to obtain further studies as a chest X ray (CXR) and electrocardiogram (ECG). However in several studies, ECG and CXR examination did no help in the diagnosis and in those cases where it was thought helpful it was often misleading. Overall, it appears that ECG and CXR examination add little to the clinical evaluation of the child with an asymptomatic heart murmur. The most cost-effective strategies for the diagnosis of heart murmurs in children could be: the paediatrician selectively refers those with suspected pathologic murmurs to a cardiologist, he refers all patients with murmurs to a cardiologist, or he refers all patients with murmurs for an echocardiogram (ECHO). These strategies could imply a high cost of health care. Even in today?s hi-tech world, the best way to correctly classify a murmur as ?innocent? or ?pathological? is by clinical evaluation with special emphasis on a careful auscultation. Concerns about a pathological cause after clinical examination should prompt a referral to a paediatric cardiologist for further assessment.