CARDIOVASCULAR CONDITIONS
The Neonatal Murmur
A practical guide for the special care nursery · The murmur heard on the newborn check
KNOW WHAT MAKES
ONE WORRYING
Well or unwell?
First decide if the baby is well or unwell. An unwell baby with a murmur is urgent until proven otherwise.
Examine fully
Colour and work of breathing, perfusion and capillary refill, femoral pulses, liver edge, and the precordium (thrill, heaves).
Pre- and post-ductal sats
Right hand and either foot. Low or differential saturations point toward cardiac disease and the newborn screen.
Innocent features vs red flags
Weigh the reassuring features against the red flags to decide who is safe for review and who needs escalation.
Decide and safety-net
Well baby with a soft murmur and normal sats and pulses: review or echo per local pathway with safety-net advice. Any red flag: escalate.
REASSURING FEATURES
- Soft (grade 1-2 / 6), systolic, at the left sternal edge
- No radiation and no thrill
- A well baby - pink, feeding, settled
- Normal femoral pulses and normal pre/post-ductal saturations
- Often varies with position and may come and go
ASSESSMENT
- Pre- and post-ductal saturations (right hand and a foot)
- Femoral pulses; four-limb blood pressure if concerned
- Full newborn examination and a set of observations
- ECG and CXR if the baby is unwell or has red flags
- Echocardiography is the definitive test - timing per local pathway
RED FLAGS - ESCALATE
- Cyanosis, or low / differential saturations
- Weak or absent femoral pulses
- Poor feeding, tachypnoea, sweating or poor perfusion
- A loud, harsh or diastolic murmur
- A baby who looks unwell, or a family history / antenatal concern
MANAGEMENT
Sort the well baby from the one who needs escalation - examine, check sats and femoral pulses, then decide.
The well baby with a soft murmur
- Reassure, feed and observe.
- Do pre/post-ductal saturations and check femoral pulses.
- Arrange review or echocardiography per your local pathway.
- Give clear safety-net advice (feeding, colour, breathing) before discharge.
The baby with red flags
- Treat as possible congenital heart disease.
- Pre/post-ductal saturations, ABC support, and gain IV access.
- If a duct-dependent lesion is possible, discuss prostaglandin (PGE1) early.
- Urgent echocardiography and cardiology; call NETS if retrieval is needed.
Before discharge
- Ensure the newborn saturation screen is done and documented.
- Do not discharge an unwell baby, or one with unexplained red flags.
- Safety-net the family and document the plan and follow-up.
- Observe colour, work of breathing, feeding and perfusion; report any change.
- Take accurate pre- and post-ductal saturations (right hand and a foot).
- Escalate a baby who looks unwell or feeds poorly, whatever the murmur sounds like.
- Support the family and reinforce safety-net advice before discharge.
How do you tell an innocent murmur from a worrying one at the cot side?
Why does a normal newborn check not fully exclude congenital heart disease?
What is your unit's pathway for a well baby with a murmur?
When would you start prostaglandin, and who would you call?
Take-home message: Most murmurs heard in the first days are innocent, and a well baby with a soft murmur, normal femoral pulses and normal pre/post-ductal saturations can usually be reviewed rather than rushed. But a murmur with any red flag - cyanosis, weak femoral pulses, poor feeding or a sick-looking baby - or a baby who deteriorates as the duct closes, needs urgent assessment for congenital heart disease. When in doubt: do the sats, feel the femorals, and escalate.
For educational purposes only. Always align management to your local guidelines and your local SCN/NICU or NETS protocols.