When I am performing an annual check-up, I frequently encounter a child with a heart murmur. 

Most of the time I can reassure the parents that it is normal. But sometimes I can’t –- and sometimes I cannot be sure myself. 

Fortunately, we can send our patients to pediatric cardiologists who can do further testing to verify that everything is normal -- or clarify what any abnormalities might be. 

Dr. Sara K. Pasquali, a pediatric cardiologist at Duke, tells us what we need to be aware of when visiting a pediatric cardiologist and whether symptoms should be of concern.

-- Dennis Clements MD, PhD, MPH

Sara K. Pasquali, MD

Your pediatrician or family doctor may refer your child to see a pediatric cardiologist for many different reasons. Pediatric cardiologists have special training in diagnosing and treating congenital heart defects and other problems affecting the heart in infants, children, and adolescents.

Pediatric cardiologists at Duke see over 10,000 patients each year in their clinic at the Duke Children’s Hospital & Health Center and other clinics in North Carolina.

Some of these reasons your child should see a cardiologist include:

Heart murmurs: Most children will have a heart murmur at some point while they are growing up, and most often this represents the normal sound blood makes as it is flowing through the growing and developing heart and blood vessels. These normal or “innocent” heart murmurs often get louder at times when your child is sick or has a fever.

Other types of heart murmurs may represent a defect in the heart such as a hole between chambers, leaking valve, or other more severe problem. These heart problems may be associated with symptoms such as problems with feeding and growing, breathing difficulties, reduced energy or activity level, or fainting. 

If your child has a heart murmur associated with any of these symptoms, or an abnormal EKG (electrocardiogram), they should see a pediatric cardiologist.

Fainting: Most often, fainting episodes are not related to the heart -- instead, fainting episodes are usually due to being dehydrated or standing for long periods of time, especially in the heat.

However, if your child has a fainting episode that occurs during exercise, is associated with heart palpitations or feeling of a fast heart beat, or has fainting spells that occur often despite drinking plenty of fluids, see a pediatric cardiologist.

The cardiologist will evaluate for any problems with the heart or heart rhythm, and for problems with the body’s regulation of blood pressure.

Chest pain: Usually chest pain is not related to the heart; instead it is caused by breathing difficulties or asthma, acid reflux, or by costochondritis -- inflammation of the cartilage next to a rib. 

Visit a pediatric cardiologist if your child has chest pain that occurs with exercise or is associated with fainting or heart palpitations.

Palpitations: Heart palpitations, or the feeling of a fast or skipped heart beat, that are associated with dizziness, weakness, nausea, turning pale in color, or fainting may indicate an abnormal heart rhythm and your child should be referred to a cardiologist for evaluation.

High blood pressure: In infants and children, high blood pressure (when compared to other children of the same age and size) is most often due to problems with the kidneys.

In older children and teenagers, obesity or a strong family history of high blood pressure may also play a role.

A pediatric cardiologist will evaluate for any heart defects that may cause high blood pressure. In addition, if your child’s blood pressure is persistently high and does not respond to changes in diet, exercise, or weight loss (if they are overweight), a pediatric cardiologist may prescribe a blood pressure lowering medication.

They may also perform an ultrasound of the heart (echocardiogram) to see if the high blood pressure has resulted in any thickening of the heart muscle.

High cholesterol: If your child is found to have high cholesterol levels or if there is a history of very high cholesterol levels that runs in your family, he or she may be referred to see a pediatric cardiologist.

The cardiologist will work with your pediatrician or family doctor to follow these levels and may prescribe a cholesterol lowering medication if needed.

Medical history: If your child has a history of other medical problems he or she may be referred to see a pediatric cardiologist.

These include certain types of genetic defects, syndromes, or birth defects. Children with these problems are at higher risk of being born with a congenital heart defect.

Family history: Your child may be referred to see a pediatric cardiologist for evaluation if there is a history in the family of congenital heart defects, sudden unexplained deaths, or heart attacks that have occurred at a young age in other family members.

-- Sara K. Pasquali, MD, is a pediatric cardiologist at Duke.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.