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What is the significance of hearing a heart murmur during the newborn physical examination?

02 March 2021
26 min read
Published:

Abstract

Background

Newborn screening for congenital heart disease (CHD) forms part of the newborn physical examination (NPE) in the UK. However, research has shown that up to 50% of cases of CHD can be missed by this examination. The purpose of this literature review is to investigate the significance of hearing an asymptomatic heart murmur at the NPE in relation to the presence of CHD.

Methodology

A critical literature review was conducted to answer the research question. The findings were discussed using a narrative synthesis approach.

Findings

There was considerable heterogeneity of results. The prevalence of murmur in newborns ranged between 0.6%–10.7%. Between 13%–67% of those newborns had some form of CHD, although many had clinically insignificant lesions. Between 2%–9% of newborns with murmurs had a form of critical CHD (CCHD). The ability to discern whether a heart murmur relates to pathology or not improves with experience. No single optimal timing for the NPE was identified. Pulse oximetry was shown to increase sensitivity of screening for CCHD.

Conclusion

There is a significant increase in the prevalence of CHD when a newborn has a heart murmur, hence referral for diagnostic echocardiography is required when a heart murmur is identified. Pulse oximetry is an important adjunct to newborn screening for CCHD. Some newborns affected by CCHD will not present with murmur at the NPE. Therefore, those caring for newborns during the early days must know the signs and symptoms of CHD so that appropriate medical assistance can be sought.

Congenital heart disease (CHD) accounts for 3%–7.5% infant deaths in high-income countries (Knowles et al, 2014; Singh et al, 2014). For this reason, screening for CHD is included in newborn examinations. In the UK, screening for CHD forms part of the newborn and infant physical examination (NIPE), which screens for conditions of the eyes, heart, hips and testes. The NIPE is a two-stage screening examination that is performed within 72 hours of life and at six weeks of age (Public Health England, 2020). This paper will focus exclusively on the newborn physical examination (NPE).

Historically, in the UK, junior neonatologists performed this examination. However, it is increasingly becoming the midwife's role (Yearley et al, 2017). Recently, the Nursing and Midwifery Council ([NMC], 2019) released their new standards of proficiency for midwives. The skills and knowledge pertaining to the NPE will now be included in the pre-registration midwifery curriculum.

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