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We would like to highlight the varying practices in the
management of cardiac murmurs in well newborn infants. Two years after the
publication of Wren's important paper on this subject urging an early
definitive structural diagnosis to be made on such infants we conducted a
telephone survey of local hospitals to assess whether practices had
Until recently it was common practice to...
Until recently it was common practice to investigate a well neonate
with a 12-lead electrocardiogram (ECG), a chest radiograph (CXR), 4-limb
blood pressure and oxygen saturation. If these investigations were normal,
infants were discharged home, to be reviewed later. Wren's paper reminds
us that there is a structural defect in 54% of newborns with a persisting
murmur. Some of these structural defects (particularly outflow tract
obstructions) may be fatal if not treated early. Wren recommended
therefore that an early definitive diagnosis should be made within the
first month of life in this group.[1,2]
We obtained data from 14 district general and 6 teaching hospitals.
Whilst one third (5/14) of district general hospitals complied with
recommendations two thirds (9/14) did not, primarily because echocardiography was not available on-site. In the latter group,
management consisted of investigations (excluding echocardiography) prior
to discharge and follow-up at 4-6 weeks in a general paediatric or
neonatal follow-up clinic. Two hospitals did not routinely follow neonates
with apparently "benign" heart murmurs. One hospital did not investigate
well infants with a murmur prior to discharge. Teaching hospitals complied
with Wren's recommendations with two thirds (4/6) obtaining an
echocardiogram before discharge and the remainder obtaining one within 2
In light of this survey we feel it is important that all perinatal
units are enabled to adopt the evidence-based recommendations by the
provision of adequate paediatric echocardiographic resources.
(1) Wren C, Richmond S, Donaldson L. Presentation of congenital heart
disease in infancy; implications for routine examination. Arch Dis Child
(2) Richmond S and Wren C. Early diagnosis of congenital heart disease.
Semin Neonatol 2001;6:27-35