TABLE 35.2 “SEVEN SS” OF INNOCENT HEART MURMURS Sensitive: changes with child’s position or with respirations Short duration: NOT holosystolic Single: no associated clicks or gallops Small: murmur limited to a small area and nonradiating Soft: low amplitude Sweet: not harsh sounding Systolic: occurs during and limited to systole, NO diastolic murmur Innocent murmurs are produced by normal blood flow through the heart The intensity of an innocent murmur varies with changes in blood return to the heart, for instance, a Valsalva maneuver decreases blood flow to the heart and causes an innocent murmur to be less intense Two important exceptions are hypertrophic cardiomyopathy (HCM) and mitral valve prolapse (MVP), both of which have intensity changes based on position and are both pathologic ( Table 35.2 ) Associated Signs and Symptoms Skin Color Central cyanosis (see Chapters 21 Cyanosis and 99 Pulmonary Emergencies ) due to a cardiac lesion may be differentiated from cyanosis due to pulmonary disease by administering 100% oxygen to the child while monitoring pulse oximetry Those with pulmonary disease may improve their oximetry reading while those with cardiac lesions often will not In older children, if clubbing of the distal fingers is present, their cyanosis is chronic and persistent Other Skin Findings Note midline surgical scars Look for petechiae, including in the conjunctivae and under the fingernails Check for erythema marginatum and subcutaneous nodules Severe pallor related to marked anemia may be associated with high-output cardiac failure Potential Signs of Cardiac Failure (See Chapter 86 Cardiac Emergencies ) Edema: More likely to be dependent and pitting in cardiac disease In the nonambulatory child, dependent edema may be best appreciated along the posterior trunk and periorbital areas, rather than the lower extremities Neck veins: Notable distention is infrequent Evaluate with the patient lying flat or propped at a 45-degree angle