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EeroJokinen

Heart Auscultation and Blood Pressure Recording in Children

Heart auscultation

  • The heart should be auscultated both precordially and between the scapulae at every child health surveillance visit.
  • Pay attention to the following:
    • loudness of the possible murmur
    • punctum maximum (PM) where the murmur is best heard
    • timing of the murmur (systolic or diastolic?)
    • nature of the murmur (crescendo or decrescendo)
    • tone (vibratory, coarse, softly hissing)
    • the area where the murmur is radiating to.
  • The second heart sound (S2) should be auscultated at the pulmonary area. Observe accentuation and splitting and whether splitting is constant (pathological; audio sample Asd (Atrial Septal Defect) Secundum) or present only during inspiration (normal).
  • If a clear murmur can be heard at the back further investigations should always be performed to rule out coarctation of the aorta (a murmur on the left side of the spine), patent ductus arteriosus, or pulmonary stenosis (a murmur on both sides).
  • For murmurs see Cardiac Murmur in a Child.

Recording the blood pressure

Equipment

  • Blood pressure is recorded with a normal stethoscope. A Doppler stethoscope Doppler Stethoscopy in Diagnostics or an oscillometric manometer (e.g. Dinamap® ) can also be used.

When to record blood pressure in children

  • Blood pressure should be recorded
    • in all children at the age of 5-6 years and always regardless of age in children with
      • 2nd degree murmur
      • even a weak murmur at the back, or
      • a weak or unpalpable femoral pulse.

Recording and interpretation of the result

  • Children below 6 months of age are examined in a supine position. Older children should sit on the lap of a parent, because the child should be calm during the recording (crying raises blood pressure).
  • The width of the blood pressure cuff has to be 2/3 of the length of the upper arm and, respectively, of the thigh.
  • Place the cuff around the upper arm when recording blood pressure from the upper extremity.
    • Auscultate with stethoscope at the cubital area. If a doppler stethoscope is used, auscultate the radial pulse.
  • When recording lower extremity pressure place the cuff around the thigh when the pressure is measured by auscultating the popliteal artery with an ordinary stethoscope. If a Doppler stethoscope or oscillometer is used place the cuff around the leg proximal to the malleoli. Auscultate the pulse from the tibialis posterior or dorsalis pedis arteries.
    • Normally the systolic blood pressure measured in the lower extremity is at least as high as that measured in the upper arm (even in a supine position). When the measurements are compared, remember that the first value is higher than subsequent values because of the child's possible anxiety.
    • If the blood pressure measured in the lower extremity is not higher than that measured in the upper arm, the finding must be controlled.
    • If the pressure measured by the ankle is even slightly lower than the upper arm pressure, record the pressures from all four limbs.
    • If the average blood pressure measured at the lower limb is more than 5 mmHg lower than the higher of the values obtained from the upper arms, refer the child to a paediatrician.
  • Hypertension in children: see Hypertension in Children