How to auscultate for heart sounds in infants and children
Intended for healthcare professionals
Evidence and practice    

How to auscultate for heart sounds in infants and children

Emily Westley Senior outpatient nurse, cardio-respiratory and intensive care directorate, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, England
Catherine Renwick Consultant nurse, cardio-respiratory and intensive care directorate, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, England
Emily Ellis Advanced nurse practitioner, cardio-respiratory and intensive care directorate, Evelina London Children’s Hospital, London, England

Why you should read this article:
  • To enhance your knowledge of the procedure for undertaking cardiac auscultation in infants and children

  • To familiarise yourself with the heart sounds that may be heard during cardiac auscultation and what these may indicate

  • To be aware of the differences between undertaking cardiac auscultation in infants and children compared with adults

Rationale and key points

This article provides an introduction to performing cardiac auscultation in infants and children aged 0-16 years, with the aim of improving children’s nurses’ knowledge and confidence in this procedure. Nurses wishing to develop competence in cardiac auscultation can use this article as a guide to complement supervised practical experience; however, it is not intended to determine an individual’s competence.

• Cardiac auscultation is a component of a structured cardiac assessment rather than a standalone tool.

• It is important to auscultate all four main heart valve areas, listening for normal heart sounds and any additional sounds.

• Several differences should be considered when auscultating heart sounds in infants and children compared with adults, including heart rate ranges and the potential need to use distraction techniques for those who are distressed.

Reflective activity

‘How to’ articles can help to update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of:

• How you think this article might help improve your practice when undertaking cardiac auscultation in infants and children.

• How you could use this information to develop your own knowledge and skills before educating others on the appropriate technique and evidence base behind auscultating heart sounds in infants and children.

Nursing Children and Young People. doi: 10.7748/ncyp.2024.e1527

Peer review

This article has been subject to open peer review and checked for plagiarism using automated software

Correspondence

c.renwick@rbht.nhs.uk

Conflict of interest

None declared

Westley E, Renwick C, Ellis E (2024) How to auscultate for heart sounds in infants and children. Nursing Children and Young People. doi: 10.7748/ncyp.2024.e1527

Disclaimer

Please note that information provided by How to articles is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed according to policy and procedures. It is the nurse’s responsibility to ensure their practice remains up to date and reflects the latest evidence

Published online: 21 October 2024

Auscultation of the heart is an important element of a structured cardiac assessment in infants and children. It is included in the widely used ABCDE (assessment, breathing, circulation, disability, exposure) approach (Resuscitation Council UK 2024) and is one of the nursing skills required by the Nursing and Midwifery Council (2018) at the point of registration. It is beyond the scope of this article to outline the elements of a full cardiac assessment in detail. However, this should include: taking a detailed history; recording vital signs, height and weight; completing a structured physical assessment that includes inspection, palpation and auscultation; conducting a heart rhythm assessment with an electrocardiogram; and considering the use of echocardiography and other imaging and/or exercise testing modalities. Auscultation is usually performed following inspection and palpation.

Recognising abnormal heart sounds through auscultation can aid diagnosis and treatment plans, as well as supporting early recognition of deteriorating patients. However, in practice, paediatric cardiac auscultation is not widely undertaken by nurses for several reasons, including their lack of competency, confidence and time, as well as the ward culture (Korkmaz Doğdu et al 2021, Beckerman 2023). It is a skill usually held by specialist nurses or advanced nurse practitioners who have undertaken specific training. Nurses do not necessarily need to have completed a paediatric assessment skills course to undertake cardiac auscultation in infants and children; however, formal training underpins the theory behind auscultation and complements clinical practice.

This article aims to improve nurses’ knowledge and confidence in undertaking cardiac auscultation in infants and children aged 0-16 years, particularly for nurses training towards an advanced practice role, those in clinical nurse specialist roles or practising in acute areas such as paediatric intensive care or emergency departments, and those who are completing or have completed a recognised paediatric assessment skills course (Royal College of Nursing 2021). The article also explains the evidence base behind cardiac auscultation and some of the differences in this procedure in infants and children compared with that for adults.

Preparation and equipment

  • Attempt to minimise noise in the surrounding environment and ensure patient privacy, for example by moving to a cubicle or separate room and reducing noise from televisions or other electrical equipment.

  • Before examining the patient, ensure that you follow infection prevention and control precautions in accordance with local policy, including effective hand decontamination. Personal protective equipment may be required in the event of a child being, or suspected of being, infectious.

  • Introduce yourself to the child and their parents or carers, stating your name and role, then explain the procedure and what you are going to do. Obtain informed parental consent for the procedure. Children aged under 16 years who are capable of making decisions can provide assent alongside parental consent.

  • Prepare the patient for the procedure to ensure they are comfortable and relaxed. This preparation may vary depending on the child’s age. For example, with younger children it may be beneficial to use a teddy on which you demonstrate listening to heart sounds to familiarise them with the procedure; with infants, the assessment should be timed around their feeding and sleep; and with older children you can ask who they want to be present during the examination.

  • Some children can find the process of being examined distressing, particularly if it is undertaken by someone unfamiliar to them. If the infant or child is crying it makes auscultation of heart sounds much more challenging, so calming them will enable a better assessment of heart sounds without added noise. Consider using age-appropriate distraction techniques involving the child’s parents or carers and/or a play specialist if available. Distraction techniques for infants may include the use of lights and attractive toys, while for older children this may involve something visual such as watching cartoons at low volume.

  • You will need a neonatal or paediatric stethoscope, suitable for the age and size of the patient. Figure 1 shows the components of a stethoscope. Many chest pieces are double-sided, with a bell and a diaphragm side; however, some combine both into a single-sided chest piece. The sounds heard should not differ when using either type of stethoscope, but the technique will need to be adjusted accordingly; for example, when using a double-sided stethoscope you will need to rotate the chest piece to listen using either the bell or diaphragm. The bell is smaller and designed for hearing low-frequency sounds, while the diaphragm is larger and designed for hearing higher-frequency sounds. Both sides can be useful in cardiac auscultation.

  • Before use, clean the earpieces, bell and diaphragm of the stethoscope in accordance with your organisation’s guidelines, for example using an antimicrobial wipe.

Figure 1.

Components of a stethoscope

ncyp.2024.e1527_0001.jpg

Procedure

  • 1. Ensure the infant or child is positioned appropriately, depending on their age, clinical status and development. For example, infants should be examined lying on their backs in a cot or in the arms of their parent or carer, while children may be examined sitting upright or lying down.

  • 2. The chest piece of the stethoscope will often be cold, which can be distressing for young patients. Warm the chest piece by rubbing it on a clean surface or in the palms of your clean hands, or alternatively conduct the auscultation over a thin layer of clothing.

  • 3. Place the earpieces in your ears, ensuring that they are facing forward so they are aligned with your ear canals and feel comfortable.

  • 4. Begin by palpating the apex of the heart, placing the bell in this location to assess the patient’s heart rate and regularity. Infants’ heart rates may range from 90-170 beats per minute. Children’s heart rates vary with age from early childhood to later childhood and may range from 60-130 beats per minute, with the normal heart rate range in adolescents being similar to that of adults at 65-120 beats per minute (Deal et al 2007).

  • 5. Auscultate the following four areas (Figure 2) using the bell and diaphragm sides of the stethoscope chest piece:

    • Aortic valve – second intercostal space, right of the sternum.

    • Pulmonary valve – second intercostal space, left of the sternum.

    • Tricuspid valve – fourth intercostal space, left of the sternum.

    • Mitral valve – fifth intercostal space, left of the midclavicular line.

  • 6. Identify S1 and S2 in each area. S1 is the first heart sound of the cardiac cycle, resulting from the atrioventricular (mitral and tricuspid) valves closing. S1 is synchronous with systole and brachial artery pulsation. To help isolate S1 in adults, the nurse would palpate the patient’s brachial pulse while listening; however, the femoral or radial pulse is easier to palpate in infants and young children. The sound is often described as ‘lub’ and is loudest at the apex of the heart.

  • 7. S2 is the second heart sound resulting from the semilunar or ventricular-arterial (aortic and pulmonary) valves closing and is synchronous with diastole. This sound is often described as ‘dub’.

  • 8. You should be able to hear S1 and S2 as distinct sounds. In each area, assess the intensity of S1 and S2, noting whether the sound is loud, soft or variable.

  • 9. Assess for splitting of heart sounds. Splitting occurs when the mitral and tricuspid valves close at different times. Split S1 is heard when the mitral component (M1) occurs slightly before the tricuspid component (T1). Split S2 is heard when the aortic and pulmonary valves close at different times. The pulmonary component (P2) of S2 is delayed relative to the aortic component (A2), causing a delay between A2 and P2. Splitting may be more challenging to hear in children because they have faster heart rates than adults.

  • 10. Listen for any additional sounds during the cardiac auscultation, such as:

    • S3 – a short, low-frequency sound occurring in early diastole. It is also referred to as a ventricular gallop and may have the cadence of the word ‘Kentucky’.

    • S4 – a dull, low-frequency sound occurring just before S1 during late diastole. It is often referred to as an atrial gallop and may have the cadence of the word ‘Tennessee’.

    • Clicks – short, high-pitched sounds like a click or snap, occurring during diastole.

    • Rubs – squeaking or crunching sounds, which may occur continuously or vary with body position or during tachycardia.

  • 11. Listen for murmurs during the cardiac auscultation and assess the intensity, quality, whether they occur in systole or diastole, and where the murmur radiates to.

  • 12. Once the procedure has been completed, decontaminate your hands in accordance with local policy. Describe and document the auscultation findings in the patient’s medical records and during the handover of care. For example, the cardiac auscultation findings might be regular rhythm, heart rate of 120 beats per minute, normal I (first) and II (second) heart sounds with no additional sounds.

  • 13. If there are any concerns, such as new findings identified on the cardiac auscultation or signs of clinical deterioration – for example a change in the patient’s National Paediatric Early Warning System (PEWS) (Royal College of Paediatrics and Child Health 2024) score – these should be escalated in accordance with the agreed pathways in your clinical area.

Figure 2.

Location of heart valve areas

ncyp.2024.e1527_0002.jpg

Evidence base

A structured cardiac assessment of a patient complements a thorough history taking, contributes to a differential diagnosis being made, and supports the arrangement of further investigations to confirm the assessment findings. Auscultation is an element of a cardiac assessment that is usually undertaken after inspection and palpation. Inspection entails an assessment of the patient’s overall appearance and may provide visual information, for example about their oxygenation level and the presence of cyanosis or abnormalities in venous pulsations. Palpation entails an assessment of the quality of the patient’s arterial pulses and any thrills (vibratory sensations) which may indicate a murmur. Auscultation entails the auditory assessment of the heart and additional sounds, which may support findings ascertained during inspection, palpation and other elements of the assessment.

Although cardiac auscultation forms an important part of paediatric nursing assessments, in practice it is not widely performed by nurses. Goldsworthy et al (2021) found that low auscultation competency was associated with a lack of hands-on experience, suboptimal teaching methods, inexperienced mentors, lack of inclusion in nurse education or training curricula, and limited access to high-quality simulation sessions. Increasing knowledge and confidence in cardiac auscultation can help to create a culture where the procedure is recognised as a core skill for nurses rather than advanced skill. To achieve this, auscultation requires a practical, systematic, hands-on learning approach, rather than based on theory alone, and requires nurses to be exposed to and repeat the procedure with different patient presentations (Cyphers et al 2019).

In infants and children, auscultation of the heart should be performed using a neonatal or paediatric stethoscope. The bell and the diaphragm of the stethoscope chest piece are designed to pick up a range of different frequency sounds created by blood flowing through the heart structures during the cardiac cycle. The sounds heard will depend on the patient’s heart rate, the structure and function of the heart, and the degree of turbulent blood flow. Some heart sounds are high pitched, such as an ejection systolic murmur, so may be best heard with the diaphragm, whereas a low-pitched pansystolic murmur may be best heard with the bell (Sumski and Goot 2020).

It is recommended that the nurse listens to all four areas with the bell and the diaphragm to distinguish between high and low frequency sounds. These sounds can provide vital information about the patient’s heart rate, synchronicity, regularity and whether there are any abnormalities, such as shunts (an abnormal pathway of blood flow in the heart) (Shahjehan and Abraham 2023), stenosis (thickening and or narrowing of a heart valve) or effusions (build-up of fluid around the heart or in pleural spaces) (Jani et al 2021).

Performing auscultation on distressed and crying infants or children can be challenging, so the nurse may need to use methods to calm or distract them before beginning the procedure (Hueckel and Leyland 2023). Visual and auditory distraction techniques can be effective in reducing anxiety and fear in children during cardiac investigations, and may therefore increase their concordance with such procedures (Goktas and Avci 2023, Yantie et al 2023). Reducing noise in the surrounding environment, where possible, will enable heart sounds to be heard more clearly (Hueckel and Leyland 2023).

Structure of the cardiac auscultation

Cardiac auscultation should be undertaken in a structured way, starting with palpation of the apex of the heart to locate the apex beat while assessing the child’s heart rate and regularity, before moving on to auscultation of the four main areas where heart sounds are best heard: the aortic, pulmonary, tricuspid and mitral valve areas. The location of the apex beat may vary according to the age of the child. From birth to approximately seven years of age, the apex beat can be palpated at the fourth left intercostal space, midclavicular line and, with increasing age, at the fifth left intercostal space, midclavicular line (Gaskin and Daniels 2021).

Following assessment of the apex beat, the nurse should start auscultating at the base of the heart, at the second left and right intercostal space either side of the sternal border, for the aortic and pulmonary valve areas (Fillipps and Bucciarelli 2015). Next, the nurse should move down the sternal border to the apex of the heart, listening at the tricuspid and mitral valve areas (fourth left intercostal space at the sternal border and fifth left intercostal space at the left midclavicular line), ensuring that they listen to heart sounds using the bell and diaphragm of the stethoscope at each position (Hueckel and Leyland 2023).

Within the cardiac cycle, changes in blood pressures in the structures of the heart cause the heart valves to open and close. The first cardiac sound, S1, occurs when the mitral and tricuspid valves close during systole, creating a ‘lub’ sound. These valves close due to increased ventricular pressure (Sumski and Goot 2020). S1 can be heard loudest at the apex of the heart (Hueckel and Leyland 2023). The second heart sound, S2, occurs when the aortic and pulmonary valves close during diastole, creating a ‘dub’ sound. S2 may be split during inspiration due to increased blood flow through the pulmonary value, delaying its closure. Splitting of S2 is present in the first three weeks of life, until pulmonary vascular resistance falls to normal levels (Fillipps and Bucciarelli 2015). S2 can be best heard at the aortic and pulmonary valve areas (Hueckel and Leyland 2023).

Cardiac auscultation findings

Normal cardiac auscultation findings in infants and children include regular heart rate and rhythm, without gallops, rubs, clicks or murmurs. However, it is important to note that the absence of a murmur does not mean there is no cardiac abnormality. Similarly, the presence of a murmur does not always indicate the presence of a cardiac abnormality.

Gallops can be heard as a third or fourth heart sound (S3 or S4), producing a ‘galloping horse’ rhythm, and they may occur in patients with heart failure (Marcus et al 2004). Rubs may be heard in patients with acute pericarditis. They produce a high frequency sound heard during atrial and ventricular systole and ventricular diastole, often heard as a crunching or squeaking sound (Chahine and Siddiqui 2022). Clicks are high pitched sharp sounds heard during systole, occurring at the aortic and pulmonary valve (ejection clicks) or the mitral and tricuspid valve (non-ejection clicks). Valvar stenosis and congenital valve abnormalities most commonly account for ejection clicks. Prolapsed mitral and tricuspid valves and congenital tricuspid valve abnormalities account for non-ejection clicks (Nemani and Pechetty 2020). Clicks may also be heard in the presence of prosthetic valves.

Murmurs are the sound created by blood flowing rapidly through the heart and can be heard with a stethoscope within or during the normal S1 and S2 sounds (Hueckel and Leyland 2023). An innocent murmur occurs due to increased flow across a normal structure during a period of high output, such as tachycardia associated with an illness or fever. In contrast, pathological murmurs are caused by turbulent flow across abnormal cardiac defects, such as shunts across a congenital heart defect (for example a ventricular septal defect) or regurgitant or stenotic heart valves (Fillipps and Bucciarelli 2015). During childhood innocent murmurs are common, affecting about one third to three quarters of children between the ages of one year and 14 years (O’Meara 2023). Less than 1% of murmurs referred to paediatric cardiologists are the result of congenital heart disease (Frank and Jacobe 2011).

Additional investigations, such as an echocardiogram, can be beneficial to confirm or exclude structural abnormalities and to confirm innocent murmurs (Huang et al 2022). Repeating auscultation with the child in lying, sitting and standing positions to hear if audible murmurs change in intensity can be useful to differentiate between innocent and pathological presentations. A disappearing murmur on standing can be a useful indicator that rules out pathological heart murmurs (Lefort et al 2017).

If a murmur is heard, it is important to listen throughout the cardiac cycle to identify whether it occurs in systole, diastole or is continuous. Palpation of the pulse to determine the timing of the murmur and where it falls in the cardiac cycle can also aid diagnosis (Hueckel and Leyland 2023). The location, timing within the cardiac cycle, pitch, volume, duration, sound and changes with patients’ status can all help to differentiate between innocent and pathologic presentations (Dornbush and Turnquest 2023). For example, an innocent murmur is most likely to be systolic, low pitch and occur with varying intensity with changes in the patient’s position or within the breathing cycle (inspiration and expiration), and worsen during exercise, anxiety and fear. In contrast, pathological murmurs may sound harsh, louder and be heard during diastole (Sumski and Goot 2020).

It is important that the nurse articulates new or concerning findings to experienced senior team members, such as an advanced nurse practitioner or designated medical practitioner, as part of agreed escalation pathways. This will support patient safety and aid the nurse’s learning as they develop their cardiac auscultation skills.

For nurses wishing to enhance their skills in undertaking cardiac auscultation in infants and children, the authors recommend finding a mentor who is skilled in this procedure to support them in clinical practice. There are also several apps available that include examples of different heart sounds to help nurses familiarise themselves with the sounds they hear during auscultation (see further resources).

Further Resources

Auscultation: Heart Sounds app

Google Play

Heart Sounds and Murmurs app

Google Play

Littmann learning: eMurmur app

Google Play

Littmann Learning: Auscultation Education app

Apple App Store

Heart Murmurs Pro app

Apple App Store

Heart Sounds Auscultation app

Apple App Store

References

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  2. Beckerman V (2023) Why Nurses Should Wear Stethoscopes. http://journals.rcni.com/nursing-standard/comment/why-nurses-should-wear-stethoscopes-ns.38.7.39.s18/full (Last accessed: 29 August 2024.)
  3. Chahine J, Siddiqui WJ (2022) Pericardial Friction Rub. StatPearls Publishing, Treasure Island FL.
  4. Cyphers NA, Mest CG, Doyle-Tadduni ME (2019) Effect of psychoacoustic learning on cardiac auscultation proficiency in nurse practitioner students. Nurse Educator. 44, 2, 79-83. doi: 10.1097/NNE.0000000000000585
  5. Deal BJ, Johnsrude CL, Buck SH (2007) Pediatric ECG Interpretation: An Illustrative Guide. Blackwell Publishing, Oxford.
  6. Dornbush S, Turnquest AE (2023) Physiology, Heart Sounds. StatPearls Publishing, Treasure Island FL.
  7. Fillipps DJ, Bucciarelli RL (2015) Cardiac evaluation of the newborn. Pediatric Clinics of North America. 62, 2, 471-489. doi: 10.1016/j.pcl.2014.11.009
  8. Frank JE, Jacobe KM (2011) Evaluation and management of heart murmurs in children. American Family Physician. 84, 7, 793-800.
  9. Gaskin KL, Daniels A (2021) Caring for children and young people with cardiovascular problems. In Glasper A, Richardson J, Randall D (Eds) A Textbook of Children’s and Young People’s Nursing. 3. Elsevier, London, 201-218.
  10. Goktas N, Avci D (2023) The effect of visual and/or auditory distraction techniques on children’s pain, anxiety and medical fear in invasive procedures: a randomized controlled trial. Journal of Pediatric Nursing. 73, e27-e35. doi: 10.1016/j.pedn.2023.07.005
  11. Goldsworthy S, Gomes P, Coimbra M et al (2021) Do basic auscultation skills need to be resuscitated? A new strategy for improving competency among nursing students. Nurse Education Today. 97, 104722. doi: 10.1016/j.nedt.2020.104722
  12. Huang Y, Zhong S, Zhang X et al (2022) Large scale application of pulse oximeter and auscultation in screening of neonatal congenital heart disease. BMC Pediatrics. 22, 1, 483. doi: 10.1186/s12887-022-03540-7
  13. Hueckel RM, Leyland C (2023) Pediatric murmurs. Nursing Clinics of North America. 58, 3, 475-482. doi:10.1016/j.cnur.2023.05.013
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  16. Lefort B, Cheyssac E, Soulé N et al (2017) Auscultation while standing: a basic and reliable method to rule out a pathologic heart murmur in children. Annals of Family Medicine. 15, 6, 523-528. doi: 10.1370/afm.2105
  17. Marcus GM, Michaels AD, De Marco T et al (2004) Usefulness of the third heart sound in predicting an elevated level of B-type natriuretic peptide. American Journal of Cardiology. 93, 10, 1312-1313. doi: 10.1016/j.amjcard.2004.01.074
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