Often, I encounter children in my clinic who have been referred by their primary care physician for evaluation and see the concern in their family’s inquiring eyes. Most are thinking: Is my child going to be OK? What tests need to be done? Are they safe procedures? In the end, most of the time, the family leaves my office smiling with the only recommendation being to follow up as needed.

The three most common indications for referral to a pediatric cardiologist are heart murmur, chest pain, and arrhythmia. Here is a summary of each so you can be more informed if your child is ever diagnosed with one of them.

HEART MURMER
Heart murmurs are sounds that are caused by the blood that circulates through the heart’s chambers, valves, and blood vessels. They can be heard using a stethoscope. Murmurs can occur in normal children so not all murmurs heard are abnormal.

Murmurs can be detected at birth or may be noticed afterwards.

Innocent heart murmurs:
The most common murmurs that prompt referral are innocent murmurs. These are usually found in about 20 percent of the population and may be heard more during sicknesses with fever, with anemia, with physical activity, with hyperthyroidism (excess thyroid hormone), and during rapid phases of growth. The last two conditions affect the speed of the blood circulating in the body.

There are different names physicians use to describe these sounds: physiologic, functional, innocent, Still’s murmur, and so on. All point to a normal heart. Innocent heart murmurs may disappear over time or may last an entire lifetime, but don’t cause any health problems. These murmurs do not need follow-up, nor do they need any exercise limitation or antibiotics before procedures.

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Most innocent murmurs disappear during adulthood, but some adults may still have them.

Abnormal heart murmurs:
Abnormal heart murmurs could be due to structural problems of the heart that are present at birth. These are called congenital heart defects. The most common of these defects are holes in the heart and heart valve and vessel abnormalities.

Acquired heart diseases, which happen after birth, can also cause abnormal heart murmurs. These may be secondary to infection of the heart, valve calcification, and rheumatic fever, to list a few.

Usually, a physical exam is enough to differentiate normal from abnormal murmurs, but additional testing may also be needed to support or help with the diagnosis. These tests are done with an electrocardiogram (ECG) and an echocardiogram, which is a heart ultrasound. Further investigation with an MRI or CT of the heart is seldom needed.

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CHEST PAIN
Children can have chest pain, too, but unlike with adult diseases, nearly 95 percent of the diagnoses are secondary to non-heart-related causes.

When children complain of chest pain, the first thing that comes to their parents’ minds is the possibility that they are having a heart attack. On the contrary, the most common reasons for chest pain in children are muscles, joint strain, or inflammation. If the ribs adjacent to the breastbone are tender, this is called costochondritis, which is a type of joint infection. This is usually relieved with a short course of ibuprofen.

Another condition that may cause chest pain in children is called Texidor’s twinge. This is actually a benign condition that is characterized by sharp pain. The pain is usually felt on the left side of the chest, and often occurs during rest. It rarely occurs more than once or twice a day and lasts only a few seconds or minutes. This is also a benign pain that resolves by itself.

Sometimes, upper respiratory infections, asthma, persistent cough, heart burn, and anxiety may also cause chest pain. Further investigation is always necessary when chest pain is very intense, long-lasting, triggered by activity, or accompanied by fever and other symptoms.

Even though rarely seen in children, some heart conditions can also cause chest pain. These are inflammation of the heart (myocarditis), arrhythmias (fast heart rhythms), coronary artery problems, and tearing (dissection) of the aorta.

When your child gets referred to a pediatric cardiologist, an ECG, and most probably an echocardiogram, will be done. Depending on the complaints, exam, and results of the initial work-up, further testing with a chest X-ray, exercise stress test, and Holter monitoring may be done.

ARRHYTHMIA
An arrhythmia is any change in the regular rhythm of the heartbeat. If your child has an arrhythmia, his or her heart might beat too fast (tachycardia) or too slow (bradycardia), or it might skip a beat, or have extra beats (premature atrial or ventricular contractions).
Some arrhythmias are more commonly seen and don’t point to any significant heart disease. Outside factors, such as fever, infection, caffeine, and certain medications can cause arrhythmia. Occasionally, arrhythmias can be seen in other family members, which then directs the diagnosis more towards genetic reasons. Arrhythmias can be together with, or secondary to, known heart conditions.

Arrhythmias may occur at any age. Most are harmless, but some can be serious. Sometimes arrhythmias can be accompanied by other symptoms, such as chest pain, difficulty breathing, dizziness, and even fainting. Usually, an electrocardiogram, and sometimes a Holter, which is 24-hour monitoring of the heart rate, are done for evaluation. If the child notices the arrhythmia during activity, a treadmill exercise test can be done if they’re old enough. Very rarely, more invasive procedures like a transesophageal electrophysiology study (TEEPS) or electrophysiology testing may be required to identify and treat the arrhythmia.

Fainting, high blood pressure, and high blood cholesterol levels are some of the other indications for referral of children to a pediatric cardiologist. We will further address these topics in upcoming issues.