The child with symptomatic heart disease is not generally much of a problem for the practicing pediatrician. He is promptly referred to a cardiac center or to a pediatric cardiologist for further evaluation. However, such is not the case with the asymptomatic child in whom a systolic murmur is heard incidentally during the course of a routine physical examination. This very Common event requires that the pediatrician decide in each instance whether the murmur can be safely ignored or whether further studies are indicated. For a detailed description of murmurs in childhood, the reader is referred to the excellent work of Castle and Craige.1

The overwhelming majority of systolic murmurs discovered in asymptomatic children are either innocent or are caused by a ventricular septal defect. The present discussion is limited to the two most common innocent murmurs, the vibratory and the pulmonic ejection murmur, and their differentiation from murmurs due to ventricular septal defect, mitral insufficiency, and other organic lesions. The venous hum, also a frequently encountered innocent murmur, is not included because it is easily recognizable by the louder diastolic component, the location over the base of the heart, and the characteristic diminution in intensity or complete disappearance with compression of the neck vessels, with movement of the head from side to side, or when the patient lies down. It is sometimes confused with the murmur of patent ductus arteriosus; but, because of the foregoing features and because it is usually located parasternally to the right rather than to the left, the differentiation is not difficult.

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