Evaluation of children with cardiac murmur using Nadas criteria


  • Mary James Department of Paediatrics, Government T. D. Medical College, Alappuzha, Kerala, India
  • Poornima K. N. Department of Paediatrics, Government T. D. Medical College, Alappuzha, Kerala, India
  • Praveen Jacob Ninan Department of Radiotherapy, Government T. D. Medical College, Alappuzha, Kerala, India




Associations, Cardiac murmur, Evaluation, Nadas criteria


Background: Pediatricians often encounter children with heart murmurs during routine follow up visits or while assessment of intercurrent illness. Clinical differentiation between pathologic and innocent murmurs would be important. It is important to identify those children who need further evaluation. The aim of the study was to evaluate whether Nadas criteria can be applied as a screening test to decide on further workup.

Methods: This was a prospective descriptive study done in Government T. D. Medical College, Alappuzha over a period of 12 months from July 2013 to June 2014. All children in the age group one month to 12 years, attending the outpatient department were screened for presence of murmur of grade 2 and more. They were further evaluated carefully. They were also studied for association of variables like maternal age, birthweight, dysmorphism and family history of heart disease. Nadas criteria was then applied to the study population. A score of 2 and 1 were given to major and minor criteria respectively.

Results: 3070 children were screened. 150 children were detected to have murmur of grade2 and more.66 children were detected to have a structural heart disease by an echo study.74% of the study population in the age group <1 year had a heart disease.8 out of 78 children with a Nadas score of 1 and 10 out of 24 with a score of 2 had a heart disease. All with a score 3 and more had congenital heart disease (CHD).

Conclusions: Nadas criteria can be used as screening test with a sensitivity of 87% and specificity of 83%. 


Webb GD, Smallhorn JF, Therrein J. Congenital heart disease. In: Zipes, Libby, Bonow, Braunwald, editors. Braunwald heart disease. 7th ed, Philadelphia: Saunders;2005:1489-1547.

Vander Linde D, Konings EE, Slager MA, Witsenburg M, Helbing WA, Takkenberg JJ, Roos-Hesselink JW. Birth prevalence of congenital heart disease worldwide: a systematic review and meta-analysis. J Am Coll Cardiol. 2011;58(21):2241-7.

Rosenthal A. How to distinguish between innocent and pathologic murmurs in childhood. Pediatr Clin North Am. 1984 Dec;31(6):1229-40.

Veasy LG. Innocent Heart Murmurs in children. In: Emmanouilides GC, Rlemenschneider TA, Allen HD, Gutgesell HP. Editors. Moss and Adams Heart disease in infants, children and Adolesents including the Fetus and young Adult. 5th ed. Blatimore, Williams and Wilkins; 1995;1:650-2.

Papadopoulos GS, Folger GM. Transient solitary diastolic murmurs in the newborn. Clin Pediatr. 1983;2:548.

Haney I, Ipp M, Feldman W, McCrindle BW. Accuracy of clinical assessment of heart murmurs by office based (general practice) paediatricians. Arch Dis Child. 1999 Nov;81(5):409-12.

Bloomfield DK. The clinical evaluation of the heart. XIII. Sounds of the atrioventricular valves. Ohio State Med J. 1963 Sep;59:916.

Danford DA, Nasir A, Gumbiner C. Cost assessment of the evaluation of heart murmurs in children. Pediatrics. 1993;91:365-8.

Ferencz C, Rubin JD, McCarter RJ, Brenner JI, Neill CA, Perry LW, et al. Congenital heart disease: prevalence at livebirth. The Baltimore-Washington Infant Study. Am J Epidemiol. 1985;121(1):31-6.

Frias JL. Genetic issues of congenital heart defects. In Gessner IH, Victoria BE (eds): Pediatric Cardiology: A problem oriented approach. Philadelphia, WB Saunders;1993:238.

Rahim F, Younas M, Gandapur AJ, Talat A. Pattern of congenital heart disease in children at teritiary care centre in Peshwar. Pak J Med Sci. 2003;19(1):19-22.

McCrindle BW, Shaffer KM, Kan JS, Zahka KG, Rowe SA, Kidd L. Cardinal Clinical signs in the differentiation of heart murmurs in children. Arch Pediatr Adolesc Med. 1996;150:169-74.

Mc Connell ME, Adkins SB, Hannon DW. Heart murmurs in pediatric patients: When do you refer? Am Fam Physician. 1999;60(2):558-65.

Park MK. Paediatric cardiology for practitioners. 5th ed. St. Louis, Mosby;2008:66- 71.

Williams HJ, Alton HM. Imaging of paediatric mediastinal abnormalities. Paediatr Respir Rev. 2003 Mar 1;4(1):55-66.






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