HPI: You see a 2-month-old for a well-child visit. She is breastfed and nurses every 2 to 3 hours during the day, but her mother reports she is not nursing as vigorously as before. She sleeps one 4-hour block at night. PMH: Birth weight was 7 pounds 5 ounces. Weight gain over the last 2 weeks reveals gain of 5 ounces per week.
PE: Fussy two-month-old Chinese infant.
CV: a new III/VI systolic ejection murmur is noted along the left lower sternal border, cap refill is brisk, skin is pink and moist.
ABD: bowel sounds noted in all quadrants.
Based on the cardiac findings of this case study, this child appears to have a still's murmur. As a sign of congenital heart defects murmurs can provide suspicions to illnesses that would require the heart to work harder. According to Punnoose, “In children, murmurs are often harmless and are just the sound of a heart working normally. These harmless murmurs are often called innocent or functional murmurs (Punnoose AR, 2012).” Stills murmur is the most common type of innocent murmur, and typically disappears into adolescence but can persist into adulthood (Mejia E, 2019). Characteristics of Stills murmurs include a soft, vibratory low-pitched systolic ejection best over left lower sternal border and apex, loudest when supine with no radiation.
Utilizing the LOCATES mnemonic is what brought me to this diagnosis. Located in the left lower sternal border. Characterized as III/VI systolic ejection murmur. Time, this a new discovery. A question that I would have like to having been included in this case study would be in regards to aggravating factors, how is the murmur affected if the patient is lying, sitting, or standing.
Differential Diagnosis
Ventricular Septal Defect (VSD)- A ventricular septal defect (VSD) is a hole between the right and left pumping chambers of the heart. Babies who do have moderate or large ventricular septal defects with excessive blood flow to the lungs will have signs of congestive heart failure. The most important sign will be the baby's growth. Babies who have significant congestive heart failure will have failure to thrive and will have difficulty maintaining a normal weight gain in the first few months of life (Cincinnati Children's Hospital, 2019).
Idiopathic Hypertrophic Subaortic Stenosis (IHSS)- is a disease characterized by marked hypertrophy of the left ventricle, involving, in particular, the interventricular septum and the left ventricular outflow tract. During systole, the hypertrophied muscle in the outflow tract often narrows this region sufficiently to produce obstruction to left ventricular ejection (EUGENE BRAUNWALD, 1964).
Atrial Septal Defect (ASD)- An atrial septa! defect (ASD) is a defect or hole in the atrial septum (Burns, 2017). This diagnosis was chosen primarily due to the similar location as the stills murmur. According to Burns et al. this murmur can be examined as a “Possible mild left anterior chest bulge or palpable lift at the left sternal border (Burns, 2017).”
Treatment
Children with a murmur may be referred to a pediatric cardiologist if there is a family history of sudden death, or the child has had chest pain with exercise, palpitations (a sensation of a rapid heartbeat), or syncope (fainting spells) (Mejia E, 2019). Otherwise, pediatric patients with innocent murmurs do not need specific follow-up or diagnostic studies.
If a cardiology referral is made typical diagnostic tests will include, a chest x-ray, electrocardiogram, echocardiogram, and a complete blood count. More extensive exams include a hyperoxia test and MRI.
Patient Education & Health Promotion
When educating parents it should be made clear that children with this type of murmur can lead normal lives. They should be informed that this murmur may come and go and may become louder at times of fever, anxiety, pain, or exercise and that activities do not need to be limited or any special precautions taken (Burns, 2017).
Another issue the parents should be educated about is feedings. It appears that the patient is going too long without feeding mainly at night and she is not receiving enough of her mother's breast milk which may be why she is fussy. Although this patient is slightly below the average range, the WHO states that “Children from 0 to 4 months should be averaging about 5.5 to 8.5 ounces per week (WHO, 2019).” Nighttime feedings should not go past four hours. By 1 to 2 months of age, a breastfed baby will probably nurse 7-9 times a day. Before the milk supply is established, breastfeeding should be "on-demand" (when the baby is hungry), which is generally every 1½ to 3 hours. As newborns get older, they'll nurse less often, and may develop a more reliable schedule. Some might feed every 90 minutes, whereas others might go 2 or 3 hours between feedings (Ben-Joseph, 2015). As there was no weight displayed in this case study one can only assume the patient is underweight.
Immunizations Due
HepB (2nd dose if not given)
Rotavirus (1st dose)
DTaP (1st dose)
Haemophilus influenzae type b (1st dose)
Pneumococcal conjugate (1st dose)
Inactivated poliovirus (1st dose
Anticipatory guidance
Infant behavior and development:
Hold, cuddle, talk, sing to baby
Learn baby’s temperament, personality
Pay attention to baby’s cues for sleep; develop schedule for naps and nighttime sleep. Put baby to bed awake but drowsy
Avoid TV and other digital media with baby
Use “tummy time” when awake
Calm baby by stroking head, gentle rocking, walking with baby in stroller
Nutrition and feeding:
Exclusive breastfeeding for about the first 6 months of life provides ideal nutrition, supports best growth and development; iron-fortified formula is recommended substitute; recognize signs of hunger, fullness; expect 6 to 8 wet cloth diapers per day or 5 to 6 wet disposable diapers, 3 to 4 stools per day; no extra fluids; burp baby at natural breaks in feeding
If breastfeeding:
Provide 8 to 12 feedings in 24 hours. Give baby vitamin D (400 IU per day). Mothers should continue prenatal vitamin with iron; healthy diet (fish, protein)
References
Ben-Joseph, E. (2015, February). Breastfeeding FAQs: How Much and How Often. Retrieved from Kids Health from Nemours: https://kidshealth.org/en/parents/breastfeed-often.html
Burns, C. E. (2017). Pediatric primary care (6th ed.). St. Louis, Missouri: Elsevier.
Cincinnati Children's Hospital. (2019, April). Ventricular Septal Defect (VSD). Retrieved from https://www.cincinnatichildrens.org/health/v/vsd
EUGENE BRAUNWALD, C. T. (1964). Idiopathic Hypertrophic Subaortic Stenosis: I. A Description of the Disease Based Upon an Analysis of 64 Patients. Circulation, 29:IV-3–IV-119. doi:https://doi.org/10.1161/01.CIR.29.5S4.IV-3
Mejia E, D. S. (2019, January). Innocent Murmur. Retrieved from StatPearls : https://www.ncbi.nlm.nih.gov/books/NBK507849/
Punnoose AR, B. A. (2012). Innocent (Harmless) Heart Murmurs in Children. JAMA, ;308(3):305. doi:doi:10.1001/jama.2012.6223
WHO. (2019). Child growth standards. Retrieved from World Health Organization: https://www.who.int/childgrowth/en/
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