Physical Exam for a Child with Congenital Heart Disease

Your child's physical exam

Your child's doctor will do an examination of your child when diagnosing or evaluating heart conditions. This exam may include a head-to-toe assessment. A physical exam can help detect possible heart conditions, or help determine how well your child is coping with existing heart problems.

Some of the areas that may indicate a problem with your child's heart health include the following:

  • The head. The doctor will check the soft spot on the top of your infant's head, known as the anterior fontanelle. The anterior fontanelle is felt throughout the first year of life. Normally, this soft spot is flat, soft, and level with the rest of the scalp. The soft spot on the top of an infant's head is examined to determine if there are dehydration problems.

    The nostrils will be examined as your child breathes. Many congenital (present at birth) heart defects can stress the lungs, causing difficult breathing. Your child's doctor can evaluate the degree of difficulty by observing whether your child's nostrils flare as he or she breathes. When the lungs are working hard, the nostrils may open up wide as a way to take in extra air.

    Lip color is an important indicator of heart disease. Normally, the inside of the lips are a pink color. A blue or purple color indicates low levels of oxygen in the blood and may indicate inadequate blood flow from heart failure, anemia, or blood loss.

  • The neck. The jugular veins and the carotid arteries are located on either side of the neck. The jugular veins bring blood from the head back to the heart for a new supply of oxygen. The carotid arteries take oxygen-rich (red) blood back to the brain. Veins and arteries that are easily visible in the neck while a child is resting may be a sign that the heart isn't pumping blood efficiently.

  • The chest. Your child's doctor will observe and feel your child's chest as well as use a stethoscope to listen to the heart and lungs.

    Difficult breathing can be caused by congenital (present at birth) heart defects. One of the problem signs that can be observed is retraction--a pulling inward of the muscles between or below the ribs, or above or below the breastbone each time a child breathes.

    Your child's doctor will listen carefully to the front and back of your child's chest with a stethoscope. He or she will listen to the heart in several different areas of the chest for abnormal sounds, such as certain murmurs, clicks, and irregular beats. Heart sounds can also be heard in the back. The heart rate will also be counted.

    Abnormal sounds may be heard in the lungs when congenital or acquired heart disease is present. Fluid may accumulate in the lungs with some heart problems, and your child's doctor will hear crackles, congestion, or other moist or "wet" sounds. Both lungs should have sounds indicating good air flow through them. Breathing sounds that are not as clear or strong in one lung as in another will need further evaluation. The breathing rate also will be counted. Fluid in the lungs may cause a child to breathe more rapidly than normal. 

  • The abdomen. Many congenital or acquired heart problems can cause problems with the body's water balance, leading to fluid retention and swelling. The liver is one of the organs that becomes swollen when the body's water balance is abnormal. Your child's doctor will feel the right side of the abdomen to see if the liver is enlarged and evaluate for swelling of the organ.

  • The arms and legs. Your child's doctor will feel your child's arms and legs to find pulses. Pulses can be found in each arm on the inside of the wrist, in the bend of the elbow, and on the inner surface of the upper arm. In the legs, pulses can be found on each side of the groin, behind the knee, on the top surface of the foot, and behind the inner ankle. Absent or overly strong pulses may indicate heart problems.

    Skin temperature is also helpful in evaluating heart disease. When the heart is not pumping effectively, it will not be able to pump enough blood to meet the body's demands. The body will restrict blood flow to nonessential areas, such as the extremities, in order to protect the brain, heart, and kidneys. The skin may become abnormally pale and cool to touch in this situation.

    Examination of the nailbeds also reveals important information about the heart. Normally, the nails are a pink color. Blue or purple nails indicate insufficient amounts of oxygen in the bloodstream, or inadequate amounts of blood in the circulation. Pale nailbeds may indicate anemia (low numbers of red blood cells in the bloodstream).

    Children with cyanotic congenital heart disease, which allows unoxygenated blood to flow to the body, may also develop a widening of the nailbeds called clubbing.

Other factors that may be considered during the exam include:

  • Growth and development status. Are the child’s height and weight as expected for his or her age?  Is the child meeting development targets for his or her age, such as walking, talking, etc.?

  • Activity level. Is the child active and busy, or does he or she tire easily? Do activities, such as walking or playing, cause shortness of breath?

The symptoms of heart disease may resemble other medical conditions or problems. Always consult your child's doctor for more information.