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Eight in 1000 infants are born with a congenital heart defect. Advances in medical and surgical care allow more than 90% of such children to enter adulthood. Pediatric cardiac care includes not only the diagnosis and treatment of congenital heart disease but also the prevention of risk factors for adult cardiovascular disease—obesity, smoking, and hyperlipidemia. Acquired and familial heart diseases such as Kawasaki disease (KD), viral myocarditis, cardiomyopathies, and rheumatic heart disease are also a significant cause of morbidity and mortality in children.
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Symptoms related to congenital heart defects primarily vary according to the alteration in pulmonary blood flow (Table 20–1). The presence of other cardiovascular symptoms such as palpitations and chest pain should be determined by history in the older child, paying particular attention to the timing (at rest or activity-related), onset, and termination (gradual vs sudden), as well as precipitating and relieving factors.
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The examination begins with a visual assessment of mental status, signs of distress, perfusion, and skin color. Documentation of heart rate, respiratory rate, blood pressure (in all four extremities), and oxygen saturation is essential. Many congenital cardiac defects occur as part of a genetic syndrome (Table 20–2), and complete assessment includes evaluation of dysmorphic features that may be clues to the associated cardiac defect.
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Cardiovascular Examination
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A. Inspection and Palpation
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Chest conformation should be noted in the supine position. A precordial bulge indicates cardiomegaly. Palpation may reveal increased precordial activity, right ventricular (RV) lift, or left-sided heave; a diffuse point of maximal impulse; or a precordial thrill caused by a grade IV/VI or greater murmur. The thrill of aortic ...