Heart Tests for Babies and Children: Types, Procedures and Results

Heart tests in infants and children are basic diagnostic methods used in cardiology to comprehensively evaluate the structural, electrical, and functional health of the heart, such as Echocardiography (ECHO), Electrocardiography (ECG), 24-hour rhythm Holter monitoring, 24-hour blood pressure Holter monitoring, and Fetal ECHO performed for examinations in the womb. In addition to these, there are also advanced evaluation methods such as cardiac magnetic resonance imaging (MRI), cardiac computed tomography (CT), angiography, scintigraphy, and evaluation of a three-dimensional model of the heart.

These pediatric applications, which make it possible to examine the heart in detail throughout the growth process extending from the prenatal period to the end of adolescence, are completely different from adult cardiology. These medical tools, specially designed for the constantly changing dynamic physiology of children, allow congenital differences or circulatory system problems that may develop later to be detected at the earliest stage. Early diagnosis is the most fundamental key to ensuring that little hearts beat healthily and safely throughout life.

What Does It Mean to Hear a Heart Murmur in Children?

The largest proportion of outpatient clinic visits consists of murmurs heard with a stethoscope during routine examinations. A murmur is not actually the name of a disease, but merely a description of a sound that is heard. It is the sound reflected onto the chest wall by the turbulence, or swirling, created as blood moves through the chambers of the heart or the major vessels leaving the heart. The vast majority of these sounds heard during childhood are called innocent murmurs. An innocent murmur means that there is no structural abnormality, hole, or narrowing in the heart.

The main reason these sounds are heard so frequently in children is related to their physical structure. The chest wall, muscle, and fatty tissue of children are significantly thinner compared with those of adults. This thinness causes the natural sounds created by completely normal blood flow inside the heart to be heard much more easily and loudly with a stethoscope. It is just like hearing the sound of water pipes in the next room through a thin wall. As the child grows, the rib cage expands, and the chest wall thickens, these innocent sounds can no longer be heard from the outside and disappear on their own.

Some serious conditions that should not be confused with innocent murmurs include:

• Holes
• Vascular stenoses
• Valve insufficiencies
• Valve stenoses

If the findings mentioned above are detected, the murmur then indicates disease.

How Is an Innocent Heart Murmur Distinguished from a Pathological Murmur That Indicates Disease?

Unlike innocent murmurs, pathological murmurs indicate a genuine anatomical problem in the heart. If we compare the structure of the heart to the rooms of a house, there may be holes in the walls between the rooms that should not be there, or the doors may fail to open fully and create obstruction. Holes between the atria or ventricles of the heart, openings that have failed to close between the major vessels leaving the heart, or narrowing of the heart valves disrupt the normal, smooth flow of blood.

Think about how water sprays out under pressure and noisily when you squeeze the end of a garden hose with your thumb; narrowing and holes in the heart likewise create much stronger turbulence sounds with a different character. Determining with certainty whether a murmur is innocent or caused by a disease does not end with listening alone. In every suspicious situation, the internal structure of the heart must be visualized with ultrasound waves to confirm the diagnosis.

The main congenital conditions that may cause a pathological murmur include:

• Atrial Septal Defect (ASD)
• Ventricular Septal Defect (VSD)
• Patent Ductus Arteriosus (PDA)
• Aortic valve stenosis (AS)
• Pulmonary valve stenosis (PS)
• Tetralogy of Fallot (TOF)

What Causes Bluish Discoloration (Cyanosis) in Newborn Babies and How Is It Related to the Heart?

During the newborn period, bluish discoloration around the baby’s lips, tongue, and skin is an extremely critical condition requiring emergency intervention. This condition, known medically as central cyanosis, indicates that the oxygen level in the blood has fallen below dangerous limits. Babies have a special type of fetal hemoglobin in their blood that binds very tightly to oxygen. Therefore, when bluish discoloration becomes visibly noticeable in a newborn, the amount of oxygen circulating in the blood has actually already fallen to critical levels.

It is necessary to quickly distinguish whether the source of the bluish discoloration originates from the lungs or the heart. Airway obstructions or lung development problems may cause bluish discoloration. However, heart-related bluish discoloration is generally caused by severe congenital heart anomalies that prevent blood from reaching the lungs and becoming oxygenated. If deoxygenated blood is pumped directly into the body without first passing through the lungs and being oxygenated, severe bluish discoloration develops in the baby. In some cases, different biochemical conditions that impair the oxygen-carrying capacity of the blood should also be considered in babies who do not have respiratory distress but whose skin appears gray-blue.

Some conditions that may be detected in newborns presenting with bluish discoloration include:

• Tetralogy of Fallot
• Pulmonary valve atresia or stenosis
• Tricuspid valve atresia or stenosis
• Airway obstructions
• Methemoglobinemia

Are Excessive Sweating During Feeding and Failure to Gain Weight in Infants Signs of Heart Disease?

During infancy, heart failure does not present with the classic symptoms seen in adults, such as swelling in the legs or chest pain. For babies, the greatest physical effort in life is feeding by sucking at the breast or from a bottle. This effort is equivalent to brisk running for us. If there is a large hole in the heart, more blood than necessary is pumped into the lungs with every heartbeat. This causes fluid accumulation in the lungs.

A baby whose lungs are filled with fluid cannot breathe comfortably. During sucking, the baby becomes short of breath, develops excessive sweating on the forehead, becomes tired before finishing the feeding, and falls asleep. Since the body uses all of its available energy for breathing and performing that exhausting sucking function, no energy remains for growth. When the energy expended exceeds the calories consumed, growth and developmental delay occur. In other words, a baby failing to gain weight compared with peers and sweating heavily during feeding is a warning sign that must be taken very seriously.

The main symptoms suggesting heart failure in infants include:

• Excessive sweating
• Rapid breathing
• Fatigue with minimal effort
• Stopping feeding before completion
• Failure to gain weight

Do Chest Pain and Palpitations in Children Always Indicate a Dangerous Heart Disease?

Contrary to the common perception and fear in society, the vast majority of chest pain in childhood is not related to the heart. While vascular blockage or a heart attack immediately comes to mind when an adult holds their chest, in children these pains are generally caused by musculoskeletal strain in the rib cage, growing pains, or lung infections. However, if the pain occurs while running, exercising, or climbing stairs, lasts for a long time, and forces the child to stop, the condition must be examined in detail.

In particular, if the pain is accompanied by paleness, cold sweating, dizziness, dimming of vision, palpitations, or fainting, underlying congenital coronary artery abnormalities, heart muscle diseases, or inflammation of the pericardium in children should be investigated. Palpitations are another issue that greatly concerns parents. However, heart palpitations do not always mean that there is an electrical disorder of the heart. External factors may often affect the heart rate.

Causes of chest pain and palpitations in children that are not heart-related include:

• Muscle strain
• Growing pains
• Gastric acid reflux
• Stress
• Test anxiety
• Anemia
• Thyroid disorders

How Is Echocardiography (ECHO) Performed to Examine the Heart in Infants and Children?

When evaluating the heart health of children, the most powerful, reliable, and frequently used tool available to us is Echocardiography, or ECHO for short. ECHO works just like the ultrasound devices used during pregnancy to monitor the baby in the womb. It enables real-time and moving visualization of the structure of the heart, the dimensions of its chambers, the thickness of the heart muscle, the opening and closing movements of the valves, and the speed of blood flow within the vessels.

Thanks to advanced color Doppler technology, the direction of blood flow is coded on the screen in blue and red, allowing backward leaks or turbulence at points of narrowing to be easily detected. The most wonderful aspect of ECHO for children is that it is completely painless and contains no radiation whatsoever. The child does not need to fast or make any special preparations before the procedure. The examination room is generally dim and quiet. Warm gel is applied to the chest area, and images are obtained by moving a device called a probe across the chest. Most children are quite comfortable during this examination, and babies may even laugh because the gel tickles them when it is applied.

Some important situations in which an ECHO examination must be performed include:

• Hearing a murmur
• Complaint of chest pain
• History of fainting
• Detection of bluish discoloration
• Growth retardation
• Frequent lung infections
• Family history of congenital heart disease

Is Cardiac Ultrasound Through the Esophagus (TEE) Necessary When Standard ECHO Is Insufficient?

Standard ECHO performed through the chest generally shows all details of the heart perfectly because children have thin chest walls. However, in some special and complex situations, it may not be possible to clearly visualize the most posterior parts of the heart, the points where the pulmonary veins enter the heart, or the back surfaces of artificial heart valves. Lung tissue or ribs located between the rib cage and the heart may block the passage of sound waves. This is where Transesophageal Echocardiography, or TEE, comes into play.

During the TEE procedure, a thin and flexible tube with a tiny ultrasound camera at its tip is passed through the mouth into the esophagus. Because the esophagus lies adjacent to the back wall of the heart, extremely high-resolution images of remarkable quality are obtained without any intervening obstruction. This method is especially vital in bacterial inflammation of the inner lining and valves of the heart. However, because swallowing the probe can be highly uncomfortable and frightening for children, the procedure is performed in pediatric patients by specialist anesthesia teams while the child is completely asleep or under deep sedation, ensuring that the child feels no pain or fear.

The medical conditions in which TEE is most frequently used include:

• Infective endocarditis
• Aortic tears
• Complex venous return anomalies
• Monitoring of artificial valves
• Real-time checks during surgery
• Placement and monitoring of devices during angiography

How Are Hidden Heart Rhythm Disorders in Children Detected with a 24-Hour Rhythm Holter Device?

Sometimes a child complains of severe palpitations that begin suddenly and disappear on their own shortly afterward. However, when the child reaches the hospital and an ECG is performed, everything may appear completely normal. A standard ECG records only a few seconds of the heart rhythm at that moment. Rhythm disorders, however, may occur only at certain times of the day, while the child is sleeping, running, or playing. A Rhythm Holter device must be used to detect these hidden and temporary arrhythmias.

A Rhythm Holter consists of several small wires attached to the child’s chest and a lightweight recording device approximately the size of a mobile phone, worn on the belt or around the neck. Depending on the child’s condition, it records the heart rhythm continuously, second by second, for 24 to 72 hours. During the recording period, the child is asked to continue normal daily life, school, and light play so that the natural environment triggering the complaints is not disrupted. If the child experiences palpitations, dizziness, or chest pain during the recording, they press a small button on the device to mark the rhythm at that moment. The physician can later examine these recordings on a computer and clearly see what was happening in the child’s heart at the exact second the button was pressed.

Some strict rules that the child and family must follow while the device is attached include:

• Not taking a shower
• Not taking a bath
• Not pulling on the wires
• Limiting mobile phone use
• Staying away from strong magnetic fields
• Not sleeping face down

Which Tests Are Performed for Blood Pressure Monitoring and Unexplained Heart-Related Fainting?

Diagnosing high blood pressure in children does not follow as straightforward a process as it does in adults. In a hospital environment, a child who becomes excited upon seeing a doctor in a white coat may temporarily have high blood pressure. A Blood Pressure Holter device is used to understand how the child’s blood pressure behaves while awake, at school, and most importantly during nighttime sleep. A cuff placed on the arm automatically inflates and deflates at certain intervals to measure and record blood pressure. Thanks to this device, a child with genuine hypertension can be easily distinguished from a child who is simply experiencing anxiety in the hospital.

On the other hand, there are children who have no structural hole or problem in the heart but frequently and suddenly faint. A Tilt Table Test is performed to test the neurological and cardiological reflexes underlying these unexplained episodes of fainting. The child is secured to a horizontal table with safety straps, and the table is slowly brought into an upright position. As blood pools in the legs due to gravity, the response of the heart and blood vessels is monitored through continuous blood pressure and pulse measurements. In this way, it is determined how the autonomic nervous system slows the heart and lowers blood pressure, allowing appropriate treatment to be planned.

The evaluations that should be performed for differential diagnosis in children with a history of fainting include:

• Detailed medical history
• Detailed family history
• Physical examination
• Echocardiography (ECHO)
• Electrocardiography (ECG)
• 24-hour Rhythm Holter monitoring
• 24-hour Blood Pressure Holter monitoring
• Tilt Table Test

How Is the Heart Health of a Baby in the Womb Examined with Fetal Echocardiography?

Congenital heart diseases are the most common group of structural anomalies in live-born babies. Detailed examination of the baby’s heart while still in the womb is truly lifesaving because it allows serious conditions requiring emergency intervention or surgery immediately after birth to be identified in advance. If a serious heart problem is detected, the expectant mother is referred, when the time of delivery arrives, to a fully equipped center where pediatric cardiology and cardiovascular surgery teams are available to intervene immediately.

Fetal Echocardiography is a remarkable method that examines the heart of the fetus in the womb using ultrasound waves through the expectant mother’s abdomen. It is completely safe, contains no radiation, and causes no harm whatsoever to either the mother or the tiny baby. It generally provides the most ideal results when performed between the 18th and 24th weeks of pregnancy. During this procedure, the position of the heart within the chest, the development of its four chambers, the arrangement of the major vessels leaving the heart, and the heart rhythm are evaluated one by one. It should not be forgotten that the great majority of babies born with congenital heart disease are born to healthy parents; therefore, this examination should be performed whenever there is any suspicion.

Some maternal and fetal risk factors that make Fetal ECHO necessary include:

• Maternal diabetes
• Maternal lupus
• Suspicion of an abnormal heart image on ultrasound
• Increased nuchal thickness
• Fluid accumulation in fetal body cavities
• Family history of congenital heart disease

Are Cardiac Angiography and Catheterization in Children Performed Only for Diagnosis?

In previous years, cardiac catheterization, or angiography as it is more commonly known among the public, was mainly performed to clearly visualize the internal structure of the heart and establish a definitive diagnosis of the disease. Today, however, thanks to the breathtaking advances in medical technology, pediatric catheterization has become a powerful alternative to open-heart surgery for many diseases. With these procedures, major heart problems in children can be treated through only a small needle puncture, without opening the rib cage or requiring days of intensive care.

The procedure generally begins by entering an artery or vein in the groin with thin, flexible tubes and advancing to the heart under X-ray guidance. Because children must remain completely still and should not be frightened during the procedure, they are fully anesthetized. Holes inside the heart can be completely closed with umbrella-like devices. Heart valves or vessels that have been narrowed since birth can be fully opened by advancing balloon-tipped catheters into the heart and inflating them under high pressure. In babies who are cyanotic and urgently need oxygen, the membranes inside the heart may be torn open, or stents may be placed in vessels that are about to close, giving the baby a chance to survive until surgical intervention.

Some conditions that can be treated without surgery through cardiac catheterization include:

• Balloon valve dilation
• Balloon vessel dilation
• Closure of holes with a transcatheter device (closure of ASD, VSD, PDA, and fistulas)
• Stent placement (in the aorta, pulmonary vessels, and inside the heart)

Why Is It Vital to Evaluate Children’s Heart Health Before They Start Sports?

Participating in sports is unquestionably important for the muscular, skeletal, and psychological development of children. However, before a child begins regular, strenuous, and especially competitive sports activities, they must be evaluated by a pediatric cardiology specialist. During sports, the heart rate and workload increase tremendously due to intense exertion. If the child has a hidden structural disease or electrical rhythm disorder that has remained silent and caused no symptoms until that day, this intense exertion may lead to sudden cardiac arrest.

Sudden cardiac deaths occurring on sports fields are generally caused by these genetic or electrical problems that give no prior warning. For example, syndromes in which the electrical current in the heart follows an abnormal shortcut pathway may cause the heart to beat at a fatal rate within seconds during intense exercise. Some diseases are triggered only by extreme excitement or an adrenaline surge. Therefore, it is very important for the physician to listen carefully to the child’s complaints and ask whether chest pain or fainting occurs during exertion. In suspicious cases, these extra electrical pathways in the heart can be identified and completely eliminated through a small ablation procedure using radiofrequency energy, allowing the child to safely return to sports.

Critical warning signs requiring detailed cardiac screening before starting sports include:

• Chest tightness during exertion
• Exercise-related fainting
• Exercise-related dizziness
• Disproportionate early fatigue
• Family history of sudden death at a young age
• Family history of rhythm disorders

Frequently Asked Questions

Prof. Dr. İbrahim Cansaran TANIDIR

Prof. Dr. İbrahim Cansaran Tanıdır is an internationally recognized specialist with nearly 20 years of clinical, academic, and interventional experience in the fields of congenital heart diseases, pediatric interventional cardiology, hybrid procedures, and radiation-reduced / fluoroscopy-free catheterization techniques.

To date, he has performed more than 10,000 pediatric cardiac catheterization procedures both in Turkey and abroad, and has pioneered advanced interventional and hybrid applications in complex structural heart diseases in our country.

His academic productivity represents a scientifically strong authority with 110 SCI/SCIE publications, 1,440 citations, and an H-index of 18 (Google Scholar, 2025).