PE23.10 - Cardiovascular System Examination in Children and Infants

Overview: Approach to the Pediatric CVS Exam

1. Inspection of the Precordium

Precordial Bulge

• Cause: Long-standing cardiomegaly causing the compliant chest wall (especially in infants) to expand outward. This is a pediatric-specific finding because the bony thorax in young children is soft and cartilaginous.
• Significance:
  • Indicates chronic cardiomegaly - the heart has been enlarged for a prolonged period
  • Seen in large left-to-right shunts (VSD, PDA, ASD with significant shunting)
  • Seen in chronic rheumatic heart disease, cardiomyopathies
  • A right-sided bulge suggests right ventricular (RV) enlargement
  • A left-sided or generalized bulge suggests left ventricular (LV) enlargement or biventricular enlargement
• Note: Adult chests are too rigid to develop this - it is almost exclusively a pediatric finding

Pulsations in the Precordium

• Left-to-right shunts with large pulmonary blood flow
• High-output states (anemia, fever, thyrotoxicosis)
• Anxiety/excitement in thin-chested children

2. Jugular Venous Pressure (JVP) - Pediatric Specifics

Assessment Technique

• Age restriction: Formal JVP assessment is only reliable and routinely performed in children older than 8 years
• The internal jugular vein (IJV) is used (not the external jugular vein, which is more easily visible but has valves and is unreliable)
• Position: semi-recumbent at 45°, head turned slightly to the left
• The IJV runs between the medial clavicle and the earlobe, under the sternocleidomastoid
• Measurement: Vertical distance from the sternal angle to the top of the venous pulsation column - normal is ≤3 cm (equivalent to Right Atrial Pressure = vertical ht. of blood column + 5 cm of H₂O; normal JVP < 8 cm H₂O or < 6 mmHg)
• The IJV shows a double waveform pulsation (a and v waves), distinguishing it from carotid artery pulsation

Why JVP is Difficult in Infants and Young Children

1. Short, fat neck - the IJV is anatomically inaccessible
2. Inability to cooperate - crying, squirming, head-turning all raise intrathoracic and thus venous pressure artifactually
3. High resting heart rate - individual waveforms (a, c, x, v, y) cannot be discerned at rates >100 bpm
4. In infants, hepatomegaly is a surrogate: Right atrial hypertension causes hepatomegaly before it causes visible JVD. A liver edge >3 cm below the right costal margin is the equivalent indicator of right-sided venous congestion in infants

JVP Waveform Analysis (when assessable - older children)

Clinical Significance of JVP in Children

3. Palpation of the Precordium

Apex Beat

• Normal location by age:
  • Neonate/infant (<2 years): 4th ICS, lateral to mid-clavicular line
  • 2-7 years: 4th-5th ICS, mid-clavicular line

  • 7 years: 5th ICS, mid-clavicular line (adult position)

• Lateral displacement: LV dilatation (large VSD, MR, DCM)
• Sustained/heaving impulse: LV hypertrophy (AS, hypertension)
• Tapping apex: Palpable S1 - mitral stenosis

Left Parasternal Heave

• Palpate with the heel of the hand along the left sternal border
• Positive heave (lift): RV enlargement/hypertrophy - seen in pulmonary hypertension, large ASD, PS, TOF

Thrills

• Systolic thrill at LUSB: PS, AS, large VSD
• Diastolic thrill at apex: Mitral stenosis (rare in children)
• Continuous thrill: PDA

4. Percussion - Relevance in Pediatric Examination

Why Percussion Has Limited Utility in Children

1. Chest X-ray is more accurate: The cardiothoracic ratio (CTR) on CXR is a far more reliable and reproducible method of assessing cardiac size. CTR >0.55 in children (>0.60 in infants) indicates cardiomegaly.
2. Small chest dimensions: The compact thorax of infants/toddlers makes demarcating cardiac dullness from lung resonance unreliable.
3. Overlying lung tissue variability: Lung hyperinflation (as in bronchiolitis, asthma) artificially narrows the area of cardiac dullness by percussion.
4. ECG and echo are more informative: These modalities provide direct chamber dimension data.

When Percussion Is Still Useful

• Pleural effusion detection: Stony dull percussion note at the lung base can indicate pleural effusion (seen in heart failure, post-cardiac surgery)
• Pericardial effusion: Gross enlargement of the cardiac shadow can be appreciated as a wide area of cardiac dullness
• Dextrocardia: Percussion helps confirm cardiac position when echocardiography is unavailable - dullness on the right with resonance on the left
• Hepatomegaly: Percussion of the right upper quadrant defines the liver span - important surrogate for right heart congestion in infants where JVP is unreliable

5. Auscultation

Practical Tips

• Use a pediatric stethoscope with bell and diaphragm
• Bell (light pressure): detects low-frequency sounds - S3, S4, mid-diastolic murmurs (e.g., mitral stenosis rumble)
• Diaphragm (firm pressure): detects high-frequency sounds - S1, S2, systolic murmurs, pericardial rub
• In infants, perform auscultation first before any distressing maneuvers
• At high heart rates (>160 bpm in neonates), it can be difficult to distinguish systole from diastole - palpate the pulse simultaneously to orient yourself

Auscultation Areas in Children

1. Mitral area (apex) - 4th/5th ICS MCL
2. Tricuspid area - 4th ICS left sternal border (LSB)
3. Pulmonary area - 2nd ICS left sternal border
4. Aortic area - 2nd ICS right sternal border
5. Erb's point - 3rd ICS LSB (useful for early diastolic murmurs of AR and PR)
6. Axilla - radiation of MR
7. Back - radiation of PS, coarctation, PDA

Heart Sounds

S1 (First Heart Sound)

• Closure of mitral (M1) and tricuspid (T1) valves
• M1 precedes T1; normally heard as a single sound
• Best heard at the apex and LLSB
• Loud S1: High output states, MS with pliable valve, short PR interval
• Soft S1: Poor LV function, MR, long PR interval
• Variable S1: Complete heart block, AF

S2 (Second Heart Sound)

• Closure of aortic (A2) and pulmonary (P2) valves
• Best heard at the base (2nd ICS)
• Physiological splitting of S2: A2 precedes P2; splitting increases on inspiration (increased RV filling → delayed P2) - normal finding in children and adolescents
• Wide fixed split S2: ASD (hallmark finding)
• Wide variable split: RBBB, PS, RV failure
• Narrow split / single S2: Pulmonary hypertension (P2 loud and early), severe AS, Eisenmenger syndrome
• Reversed (paradoxical) split: LBBB, severe AS

S3 (Third Heart Sound)

• Low-frequency sound at the apex, heard in early diastole (during rapid ventricular filling)
• Can be normal in children (physiological S3) - especially thin, athletic children
• Pathological S3: Dilated cardiomyopathy, large left-to-right shunt (e.g., large VSD), heart failure
• Best heard with the bell of the stethoscope

S4 (Fourth Heart Sound)

• Low-frequency presystolic sound (atrial gallop)
• Always pathological in children
• Indicates reduced ventricular compliance
• Seen in: severe hypertension, severe AS, HCM, cardiomyopathy

Gallop Rhythms

• S3 gallop (proto-diastolic): Suggests ventricular dysfunction or volume overload
• S4 gallop (presystolic/atrial): Suggests stiff, non-compliant ventricle
• Summation gallop: When S3 + S4 fuse (seen in tachycardia) - sounds like a horse's gallop

Murmurs: Key Features to Assess

• Grade I: Very faint; only heard in quiet room
• Grade II: Faint but easily heard
• Grade III: Moderate; no thrill
• Grade IV: Loud; thrill present
• Grade V: Very loud; heard with stethoscope barely on chest
• Grade VI: Heard without stethoscope

Innocent vs. Pathological Murmurs

• Grade III/IV or higher with thrill
• Diastolic or continuous murmur (almost always pathological)
• Abnormal S2 (fixed split, loud P2, single S2)
• Pan-systolic or early systolic murmur
• Associated symptoms (cyanosis, poor weight gain, syncope, exercise intolerance)
• Radiation to axilla or back
• Harsh/blowing character

Common Murmurs in Children

Pericardial Friction Rub

• Scratchy, to-and-fro sound heard in pericarditis
• Best heard at left sternal border with patient leaning forward
• Three components: atrial systole, ventricular systole, ventricular diastole
• Unlike pleural rub: persists when breath is held

6. Other Systems to Complete the CVS Examination

Peripheral Pulses

• Brachial (infants), radial (older children)
• Femoral pulses: Always palpate - radio-femoral delay indicates coarctation of the aorta (essential to not miss)
• Pulse character: Collapsing (PDA, AR), bounding (large shunts), weak/absent (coarctation, tamponade)

Blood Pressure

• Four-limb BP in suspected coarctation: >20 mmHg difference between upper and lower limbs is significant
• Age-appropriate cuff size is mandatory

Respiratory System

• Tachypnea is the earliest sign of cardiac decompensation in infants
• Pulmonary rales indicate left heart failure (less common in infants due to adaptive lymphatic drainage)
• Pleural effusion (stony dull, absent breath sounds) suggests decompensated heart failure

Abdomen

• Hepatomegaly (>3 cm below RCM in infants; >2 cm in children): surrogate for raised JVP and right heart congestion
• Splenomegaly: infective endocarditis, congestive splenomegaly
• Pulsatile liver: severe TR, markedly elevated right heart pressures
• Ascites: severe right heart failure, constrictive pericarditis

Periphery

• Clubbing: Cyanotic CHD, infective endocarditis
• Cyanosis: Central (tongue/mucous membranes) or peripheral
• Edema: Dependent (sacral in infants who lie flat, ankle in older children); periorbital in infants
• Splinter hemorrhages: IE
• Osler nodes / Janeway lesions: IE

Summary Framework for the Exam

General → Vitals (HR, RR, BP 4 limbs, SpO₂) → Peripheral signs (clubbing, cyanosis, edema)
→ Pulses (radial, femoral, character)
→ JVP (>8 years only; use hepatomegaly as surrogate in infants)
→ Precordium Inspection (bulge, visible pulsations, scars)
→ Palpation (apex beat, parasternal heave, thrills, pulsations)
→ Percussion (limited role; mainly for pleural effusion, hepatomegaly, dextrocardia)
→ Auscultation (S1, S2, added sounds, murmurs, rub)
→ Lung bases (rales, effusion)
→ Abdomen (hepatomegaly, splenomegaly)

• Precordial bulge = chronic cardiomegaly in children; adult chests are too rigid for this
• JVP is not reliably assessable below age 8; use hepatomegaly as the equivalent marker of right heart congestion in infants
• Percussion has limited utility; CXR, ECG, and echo are far more informative
• S3 can be physiological in children; S4 is always pathological
• Fixed split S2 = ASD until proven otherwise
• Loud P2 = pulmonary hypertension
• Disappearance of a murmur on standing is the strongest predictor of an innocent murmur (98% PPV)
• Always palpate femoral pulses to exclude coarctation

PE23.10 - Cardiovascular System Examination: Children & Infants (With Images)

Overview: The Pediatric Approach

1. Inspection of the Precordium

Precordial Bulge

• Indicates long-standing cardiomegaly (the heart has been enlarged for a prolonged period)
• A left-sided bulge suggests LV enlargement or biventricular enlargement
• A right-sided (parasternal) bulge suggests chronic RV enlargement
• Causes: Large left-to-right shunts (VSD, PDA, large ASD), chronic rheumatic heart disease, dilated cardiomyopathy

Pulsations in the Precordium

2. Jugular Venous Pressure (JVP)

The JVP Waveform

JVP Assessment - Pediatric Specifics

• Short, fat necks make the IJV inaccessible
• Crying and movement falsely raise intrathoracic pressure
• High heart rates (>100 bpm) prevent discernment of individual waveforms
• Use hepatomegaly as the surrogate - liver >3 cm below the right costal margin in infants = right atrial hypertension

1. Semi-recumbent position at 45°, head turned slightly left
2. Identify the IJV running from the medial clavicle to the earlobe, under the sternocleidomastoid
3. The IJV shows a double waveform (a + v) distinguishing it from the carotid (single pulse)
4. Measure vertical distance from sternal angle to top of pulsation: normal ≤3 cm (= RAP <8 cmH₂O)

JVP Waveform Components

Clinical Significance of JVP Changes

3. Palpation of the Precordium

Apex Beat

• Normal location by age:
  • Neonate/infant (<2 yrs): 4th ICS, lateral to mid-clavicular line
  • 2-7 years: 4th-5th ICS, mid-clavicular line

  • 7 years: 5th ICS MCL (adult position)

• Lateral displacement = LV dilatation
• Sustained/heaving impulse = LV hypertrophy
• Tapping apex = palpable S1 (mitral stenosis)

Parasternal Heave

• Heel of hand along left sternal border
• Positive lift/heave = RV enlargement (pulmonary hypertension, large ASD, PS, TOF)

Thrills (palpable murmurs)

• Systolic thrill at LUSB: PS, AS, large VSD
• Continuous thrill: PDA
• Diastolic thrill at apex: MS (rare in children)

4. Percussion - Relevance in Pediatric Examination

1. Chest X-ray is more accurate - CTR >0.55 (>0.60 in infants) on CXR reliably indicates cardiomegaly
2. Small chest - compact thorax makes demarcating cardiac dullness unreliable
3. Lung hyperinflation (bronchiolitis, asthma) artificially narrows the area of cardiac dullness
4. Echo and ECG are superior for chamber dimensions

• Detecting pleural effusion (stony dull at base) - seen in heart failure, post-cardiac surgery
• Confirming dextrocardia when imaging is unavailable
• Defining hepatomegaly (right upper quadrant percussion to define liver span - surrogate for right heart congestion in infants)

5. Auscultation

5 Areas for Auscultation

1. Aortic - Right 2nd ICS
2. Pulmonary - Left 2nd ICS
3. Erb's point - Left 3rd ICS (AR, PR murmurs)
4. Tricuspid - Left 4th ICS lower sternal border
5. Mitral - Apex (5th ICS MCL)

• Use bell (light pressure) for low-frequency sounds: S3, S4, mid-diastolic rumble
• Use diaphragm (firm pressure) for high-frequency: S1, S2, systolic murmurs, pericardial rub
• In infants: auscultate first before any distressing maneuver; palpate pulse simultaneously to orient systole vs diastole at rapid heart rates

Heart Sounds

S1 - "LUB"

• Closure of mitral (M1) + tricuspid (T1) valves; marks start of systole
• Best heard at apex and LLSB
• Loud S1: MS (pliable valve), high output state, short PR
• Soft S1: Poor LV function, MR, long PR
• Variable S1: Complete heart block, AF

S2 - "DUB"

• Closure of aortic (A2) + pulmonary (P2) valves; marks end of systole
• Best heard at the base (2nd ICS)
• Physiological splitting (A2 before P2, widens on inspiration): normal in children and adolescents

S3 - Early diastolic (rapid ventricular filling)

• Low frequency; heard at apex with bell
• Can be physiological in children (thin, athletic)
• Pathological: Dilated cardiomyopathy, large VSD, heart failure

S4 - Presystolic (atrial gallop)

• Always pathological in children
• Reduced ventricular compliance
• Seen in: severe AS, HCM, cardiomyopathy, severe hypertension

Murmurs

Murmur Timing - Key Patterns

• Systolic ejection (crescendo-decrescendo): AS, PS
• Holosystolic/Pansystolic: VSD, MR, TR
• Mid-systolic click + late systolic: MVP
• Early diastolic decrescendo: AR, PR
• Mid-diastolic rumble: MS, relative tricuspid stenosis in ASD
• Continuous "machinery": PDA

Innocent vs. Pathological Murmurs - Locations & Types

Levine Grading of Murmur Intensity

Key Murmur Quick Reference

Innocent Murmur Features (7 S's)

Pericardial Friction Rub

• Scratchy, to-and-fro, three-component sound (atrial systole + ventricular systole + diastole)
• Best heard: LLSB with patient leaning forward, breath held in expiration
• Distinguishing feature: persists when breath is held (unlike pleural rub)
• Seen in: pericarditis (viral, post-surgical, rheumatic, uraemic)

6. Completing the Examination - Other Systems

Peripheral Pulses

• Always palpate femoral pulses - radio-femoral delay = coarctation of aorta
• Collapsing/bounding pulse: PDA, AR, high-output states
• Weak/absent pulses: coarctation, tamponade, severe LV failure

Blood Pressure (4-limb)

• 20 mmHg upper-to-lower limb gradient = coarctation

Respiratory System

• Tachypnea = earliest sign of cardiac decompensation in infants
• Pulmonary rales = LVF (less common in infants due to good lymphatic drainage)
• Stony dull + absent breath sounds at lung base = pleural effusion

Abdomen

• Hepatomegaly (>3 cm below RCM in infants) = right heart congestion surrogate for JVP
• Pulsatile liver = severe TR / markedly raised right heart pressures
• Splenomegaly = infective endocarditis, congestive splenomegaly

Peripheral Signs

• Clubbing: Cyanotic CHD, infective endocarditis
• Central cyanosis (tongue, mucous membranes): Right-to-left shunts
• Edema: Sacral (infants lying flat), ankle (older children)
• Splinter hemorrhages / Osler nodes / Janeway lesions: Infective endocarditis

Summary Examination Framework

General inspection
    ↓
Vitals: HR, RR, SpO₂, BP (4 limbs)
    ↓
Peripheral signs: clubbing, cyanosis, edema, splinter hemorrhages
    ↓
Pulses: rate, rhythm, character, radio-femoral delay
    ↓
JVP: only >8 yrs; hepatomegaly as surrogate in infants
    ↓
Precordium INSPECTION: bulge → visible pulsations → scars
    ↓
PALPATION: apex beat → parasternal heave → thrills → epigastric pulsation
    ↓
PERCUSSION: limited role → pleural effusion, hepatomegaly, dextrocardia
    ↓
AUSCULTATION: S1 → S2 (splitting) → S3/S4 → murmurs → rub
    ↓
Lung bases: rales, dullness (effusion)
    ↓
Abdomen: hepatomegaly, splenomegaly, pulsatile liver

• Precordial bulge = chronic cardiomegaly; adult chests are too rigid for this
• JVP unreliable below age 8 - use hepatomegaly as the equivalent sign
• Percussion has limited utility; supplement with CXR, ECG, echo
• S3 can be physiological in children; S4 is always pathological
• Fixed split S2 = ASD until proven otherwise
• Loud P2 = pulmonary hypertension
• Murmur disappearing on standing = innocent with 98% positive predictive value
• Always palpate femoral pulses - missing radio-femoral delay = missing coarctation

PE23.10 - Cardiovascular Examination in Children & Infants

Full Step-by-Step Illustrated Guide

STEP 1: General Inspection & Peripheral Signs

Clubbing + Cyanosis

• Place dorsal surfaces of two matching fingers together
• Normally a diamond-shaped window is visible at the nail bases
• In clubbing, this window is obliterated
• Causes in cardiac patients: cyanotic CHD, infective endocarditis

• Indicates SaO₂ <85% - significant right-to-left shunting
• Always check the tongue - peripheral cyanosis of cold hands can be normal

STEP 2: Inspection of the Precordium

Precordial Bulge

• Left-sided bulge → LV or biventricular enlargement (large VSD, PDA, DCM)
• Right-sided (parasternal) bulge → Chronic RV enlargement (large ASD, severe PS, TOF)
• Indicates long-standing cardiomegaly; cannot develop acutely

Visible Pulsations

STEP 3: Jugular Venous Pressure (JVP)

Anatomy and Measurement Technique

1. Patient semi-recumbent at 45°, head turned slightly left
2. Identify the IJV path: from medial clavicle → earlobe, running under the sternocleidomastoid
3. The IJV shows a double waveform (a + v) - this distinguishes it from the carotid (single pulsation)
4. Measure the vertical height from the sternal angle to the top of the pulsation column
5. Normal = ≤3 cm (equivalent to RAP ≤8 cmH₂O)

JVP Waveform Interpretation

Why JVP Cannot Be Assessed in Infants and Young Children

STEP 4: Palpation

Apex Beat Character

• Infant <2 years: 4th ICS, lateral to MCL
• 2-7 years: 4th-5th ICS, MCL

• 7 years: 5th ICS MCL (adult position)

Parasternal Heave

• Place the heel of the hand along the left sternal border
• A positive heave lifts your entire hand with each systole
• Indicates RV enlargement/hypertrophy
• Causes: pulmonary hypertension, large ASD, PS, TOF, mitral stenosis

Thrills (Palpable Murmurs = Grade IV+)

STEP 5: Percussion

STEP 6: Auscultation

5 Areas to Listen

1. Aortic - Right 2nd ICS
2. Pulmonary - Left 2nd ICS
3. Erb's point - Left 3rd ICS (AR, PR early diastolic murmurs)
4. Tricuspid - Left 4th ICS lower sternal border
5. Mitral - Apex (5th ICS MCL)

• Bell (light touch): S3, S4, mitral stenosis rumble - low frequency sounds
• Diaphragm (firm pressure): S1, S2, all systolic murmurs, pericardial rub - high frequency
• In infants: auscultate before any painful/distressing step; palpate pulse simultaneously to identify systole at high heart rates

S2 Splitting Patterns - Clinical Significance

• Physiological split (widens on inspiration, disappears on expiration) = NORMAL in children and adolescents
• Fixed split (same in inspiration and expiration) = ASD until proven otherwise
• Loud P2 heard beyond the pulmonary area = pulmonary hypertension
• Single S2 = severe pulmonary hypertension (Eisenmenger), severe AS

Murmur Types - Timing Diagrams

Innocent vs. Pathological Murmurs - Location Map

• Location on the precordium
• Age of presentation
• Character and pitch
• Radiation
• Change with position

Innocent Murmur Features (7 S's)

Levine Grading Scale

STEP 7: Completing the Examination - Abdomen

Hepatomegaly: The JVP Surrogate in Infants

• Start palpation from the right iliac fossa and move upward
• Lower border: palpation → the liver edge is felt below the right costal margin
• Upper border: percussion downward from the right lung → note where resonance becomes dull
• Liver span (normal by age): 4.5-5 cm in neonates, up to 8 cm in 12-year-olds
• Abnormal: Liver edge >3 cm below right costal margin in infants = hepatomegaly = right heart congestion

Summary: Examination Framework at a Glance

STEP 1: General + Peripheral Signs
        ↓ Clubbing, central cyanosis, edema, splinter hemorrhages

STEP 2: Vitals
        ↓ HR, RR, SpO₂, BP (4 limbs - femoral = coarctation screen)

STEP 3: Inspect Precordium
        ↓ Precordial bulge → visible pulsations → scars → chest shape

STEP 4: JVP (>8 yrs only; hepatomegaly as surrogate in infants)
        ↓ Height, waveform, Kussmaul's sign

STEP 5: Palpate Precordium
        ↓ Apex beat (site, character) → parasternal heave → thrills

STEP 6: Percuss
        ↓ Pleural effusion, hepatomegaly, dextrocardia

STEP 7: Auscultate
        ↓ S1 → S2 (splitting pattern) → S3/S4 → murmurs → rub
        ↓ Lung bases (rales, dullness)

STEP 8: Abdomen
        ↓ Hepatomegaly, splenomegaly, pulsatile liver

1. Precordial bulge = chronic cardiomegaly - unique to children (compliant chest wall)
2. JVP unreliable <8 years - use hepatomegaly as your right-heart pressure gauge
3. Fixed split S2 = ASD until proven otherwise - never normal
4. Murmur disappears on standing = innocent (98% PPV) - the single best bedside test
5. Always palpate femoral pulses - radio-femoral delay = coarctation of aorta