Neonatal murmurs: are senior house officers good enough? (Audit).

Aim: To show that, given appropriate guidelines, senior house officers (SHOs) have the clinical skills required to assess neonatal murmurs.

Methods: Neonatal SHOs identified babies with a cardiac murmur at routine neonatal examination. The SHOs assessed whether the murmur was significant or innocent and decided between immediate further assessment or echocardiogram as an outpatient.

Results: A total of 112 babies had murmurs at routine neonatal examination. The incidence of cardiac murmurs was 13.8 per 1000. Twelve babies were referred for immediate further assessment. Eleven had structurally abnormal hearts. One had a normal heart with pulmonary hypoplasia. One hundred babies were referred, and 78 attended for outpatient follow up. Of these, the SHO assessed nine babies as having a significant murmur and 69 as having an innocent murmur. Twenty two babies failed to attend for follow up; all were thought to have innocent murmurs. Of the nine murmurs assessed as significant, four were confirmed as such and five were found to be innocent. Of the 91 murmurs assessed as innocent, 63 were proven to be innocent, six had abnormalities on echocardiagram, and 22 defaulted to follow up. Five of the serious murmurs were small ventricular septal defects, which had resolved by 6 months of age; the other had mild pulmonary stenosis. None of these babies were clinically symptomatic at outpatient review.

Conclusion: Given appropriate guidelines, SHOs have the skills to assess the significance of, and decide on appropriate management for, neonatal murmurs. Electrocardiograms and chest radiographs are not necessary.

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The management of babies found to have a cardiac murmur at the routine neonatal examination varies between neonatal units. Initial management may involve review by the registrar or consultant plus an electrocardiogram (ECG) and chest radiograph (CXR). These actions may delay discharge and cause parental anxiety.

Delay in diagnosis of congenital heart disease (CHD) can have serious consequences, causing compromise to the baby and distress to the family. A normal neonatal examination does not exclude CHD, and routine examination may fail to detect more than half of the cases of CHD. (1) The routine neonatal examination performs poorly as a screening test. (2) An echocardiogram is necessary for accurate diagnosis of CHD. However, clinical examination can determine the presence or absence of CHD and thus an echocardiogram may be unnecessary for those with clinically innocent murmurs many of which resolve spontaneously. (3-5) Immediate echocardiogram is not available in most units, and early referral to a paediatric cardiology centre is suggested. (2,6) However, delay in assessment is inevitable in some cases, thus it is highly desirable that senior house officers (SHOs) are maximally equipped with the skills to detect significant heart disease as early as possible.

Unless an SHO has taken a postgraduate examination, their clinical skills are rarely observed and assessed. Examination of the newborn is well documented in clinical texts, but SHOs may only read these if studying for postgraduate examinations, and many SHOs may only be equipped with the neonatal examination routine taught as a medical student.

The aim of our study was to show that, given appropriate guidelines:

(1) SHOs are able to assess the significance of cardiac murmurs in newborn babies;

(2) SHOs can assess the need for immediate review or outpatient follow up;

(3) it is safe to dispense with routine ECGs and CXRs.

SUBJECTS AND …