Dear Editor

We would like to highlight the varying practices in the management of cardiac murmurs in well newborn infants. Two years after the publication of Wren's important paper on this subject[1] urging an early definitive structural diagnosis to be made on such infants we conducted a telephone survey of local hospitals to assess whether practices had changed.

Until recently it was common practice to investigate a well neonate with a 12-lead electrocardiogram (ECG), a chest radiograph (CXR), 4-limb blood pressure and oxygen saturation. If these investigations were normal, infants were discharged home, to be reviewed later. Wren's paper reminds us that there is a structural defect in 54% of newborns with a persisting murmur. Some of these structural defects (particularly outflow tract obstructions) may be fatal if not treated early. Wren recommended therefore that an early definitive diagnosis should be made within the first month of life in this group.[1,2]

We obtained data from 14 district general and 6 teaching hospitals. Whilst one third (5/14) of district general hospitals complied with recommendations two thirds (9/14) did not, primarily because echocardiography was not available on-site. In the latter group, management consisted of investigations (excluding echocardiography) prior to discharge and follow-up at 4-6 weeks in a general paediatric or neonatal follow-up clinic. Two hospitals did not routinely follow neonates with apparently "benign" heart murmurs. One hospital did not investigate well infants with a murmur prior to discharge. Teaching hospitals complied with Wren's recommendations with two thirds (4/6) obtaining an echocardiogram before discharge and the remainder obtaining one within 2 weeks.

In light of this survey we feel it is important that all perinatal units are enabled to adopt the evidence-based recommendations by the provision of adequate paediatric echocardiographic resources.

References
(1) Wren C, Richmond S, Donaldson L. Presentation of congenital heart disease in infancy; implications for routine examination. Arch Dis Child 1999;80:F49-F53
(2) Richmond S and Wren C. Early diagnosis of congenital heart disease. Semin Neonatol 2001;6:27-35