Position of the Apex Beat in Childhood

Arch Dis Child: first published as 10.1136/adc.53.7.585 on 1 July 1978. Downloaded from

Archives of Disease in Childhood, 1978, 53, 585-589

Position of the apex beat in childhood

ASUQUO U. ANTIA, STEFAN R. MAXWELL, ALIGH GOUGH, AND 0. AYENI From the Department ofPaediatrics, University of the West Indies, Mona, Kingston, Jamaica, and Department ofPreventive and Social Medicine, University of Ibadan, Nigeria

SUMMARY The position of the apex beat in relation to the midclavicular and nipple lines and the intercostal spaces was studied in 353 healthy Jamaican children from birth to 10 years. The traditional use of the midclavicular line as a reference point in relation to the apex beat is not an accurate index of normal heart size at all ages. For this purpose actual measurement of the apex beat, which ranges between 2 - 8 and 5 *4 cm from the midline, should be made. However, for a rough estimate of normal cardiac size the midclavicular line may be used. In contrast, the nipple line lies outside the apex beat at all ages; it should not be used in the clinical evaluation of normal cardiac size. From birth to age 3 years the apex beat is located in the 4th intercostal space and with increasing age gradually moves into the 5th space in most children.

In clinical practice the intercostal space (ICS), the Subjects and methods midclavicular line (MCL), and sometimes the nipple line (NPL) are used as reference points to assess the The subjects consisted of healthy Jamaican children position of the apex beat (AB). While some authors selected from among (a) newborn babies in the (White, 1951; Dammann, 1959) state that the AB obstetric wards, and also those attending the infant in normal children of all ages is in the fourth left welfare clinic, University College Hospital of the intercostal space (4LICS), others (Julian, 1970; West Indies, Kingston, (b) children attending day- Julian and Turner, 1974) assert that irrespective of care nurseries, and (c) children attending the Mona age the AB is usually in the fifth space (5LICS). With Primary School and the Hope Valley experimental http://adc.bmj.com/ regard to the relationship of the AB to the mid- School in Kingston, Jamaica. The children were clavicular line (MCL), White (1951) states that in selected after appropriate clinical examination to children of all ages it is normally beyond this line. exclude cardiorespiratory disorders and chest In contrast, Julian (1970), and Julian and Turner deformities. Any child with a cardiac murmur was (1974) have reported that the AB is at or within the excluded even if it was thought to be an innocent MCL. These assertions may be correct as far as they murmur. Similarly children with any degree of respiratory disorder were excluded. concern adults as all the authors, except Dammann, on September 30, 2021 by guest. Protected copyright. are eminent cardiologists who deal primarily with The AB, defined as 'the furthermost point of adults. The only other reference to the normal AB visible cardiac pulsation in the praecordium down- in childhood is by Kaplan (1975), who states that wards and to the left at which the finger is distinctly the AB is in the 4LICS from birth to age 2 years and lifted' (Julian and Turner, 1974), was determined in thereafter is in the 5LICS. It is also noteworthy that the erect position in children aged between one and no standard textbooks on paediatric cardiology 3 years, in the supine position in the newborn babies, (Taussig, 1960; Nadas, 1963; Keith et al., 1967; and in both the erect and supine positions in the Watson, 1968) attempt to define the position of AB others. The AB was evaluated in each child inde- in normal children. pendently by 3 investigators. Before the study started In view of the above seemingly contradictory each investigator had examined several normal statements the present study was undertaken to children of different ages to ensure there was close evaluate clinically the AB in relation to the MCL, agreement on the methodology. In adopting this NPL, ICS, and chest circumference in normal procedure the investigators were satisfied that children of different ages. observer errors were eliminated or were of little significance. Furthermore, measurement from the midline of the AB, as well as all other measurements undertaken by S.R.M. and A.G. were confirmed Received 9 January 1978 by A.U.A. 585 Arch Dis Child: first published as 10.1136/adc.53.7.585 on 1 July 1978. Downloaded from

586 Antia, Maxwell, Gough, and Ayeni

The midline was established by joining a central Table 2 Mean apex beat distances from the midline point in the suprasternal fossa to the xiphisternal in supine and erect positions for both sexes and angle, and the distance of the AB and of the nipple according to age was measured from this midline. The extreme medial Age Supine Erect Student's were identified (years) t-value P and lateral ends of the left clavicle n x SD n x SD and the corresponding points on the skin marked with ink. The length of the clavicle represented by N 20 2.8 0.4 1- - - - 11 3.8 0-4 - those points marked on the skin was similarly 2- - -- 17 4.1 0-7 - - measured. Half of the clavicular length was taken as 3- - - - 12 4.7 0.3 - - 4- 14 4.6 0.5 14 4.6 0.4 0.00 >0-9 corresponding to the MCL. During measurements 5- 37 4.9 0.7 37 5.0 0.8 0.57 >0-5 in both the erect and supine positions, the upper arms 6- 48 5.0 0-8 48 5.1 0.5 0.73 >0-4 were the chest wall so as not 7- 48 5.0 0.7 48 5.2 0.7 1.40 >0. 1 lightly pressed against 8- 52 5.3 0.8 52 5.4 0.6 0.72 >0-4 to stretch the skin. The chest circumference in full 9- 48 5.3 0-7 48 5-5 0.5 1.61 >0.1 inspiration was measured at the level of the nipples. 10- 46 5-3 0-7 46 5-7 0-6 2-94 <0-01* All measurements were recorded on the centimetre i = mean; SD = standard deviation; n = number of subjects; scale to the nearest millimetre. N = neonate. 60 Results Out of 1000 children examined clinically, 353 (167 boys and 186 girls) were selected for the study; their E 5.5 ages ranged from birth to 10 years. 337 of the v subjects were of Negro descent, 10 were Chinese, and 6 Indian. Vi Table 1 gives the man distances, in erect position, of the AB, MCL, and NPL from the midline. The mean AB distances ranged between 3 * 8 and 5 *7 cm for both sexes and increased with increasing age. In ._ the age group 1 to 3 years, the mean distance of the a MCL was significantly less (P<0 05) than that of the AB. By contrast, the mean distance of the MCL § 45- http://adc.bmj.com/ at ages 4, 9, and 10, was greater (P<0 05) than that of the AB. The mean distance of the NPL at all ages was consistently greater than that of the AB and MCL, the difference being highly significant 4L0 (P<0-001). Fig. 1 shows the mean (±2SE) apical 45 6 78 10 distance in the erect position for children aged Age (years) 4 and 10 years. The progressive increase in between Fig. 1 Mean 2SE of the apical distance from on September 30, 2021 by guest. Protected copyright. the mean values with increasing age is evident. the midline in erect position according to age. Table 2 shows the mean apical distances in the Note the progressive increase in the mean values with erect and supine positions. It will be observed that increasing age.

Table 1 Mean apex beat (AB), midclavicular line (MCL), and nipple line (NPL) distances for both sexes from the midline in erect position according to age Age (years) No. ofchildren Mean distance (cm) ± SD Student's t-values AB MCL NPL AB v. MCL AB v. NPL MCL v. NPL 1- 11 3-8+ 04 3-4 0-3 5-2 + 0-4 2-65* 8.21** 11.94** 2- 17 4.1 i 0.7 3-7 + 0-6 5-6 ± 0.5 1.79 7-19** 10-03** 3- 12 4-7 + 0.3 4-2 + 0.3 5-6 ± 0.5 4.08** 5.35** 8-32** 4- 14 4.6 i 0-4 4.9 i 0.3 6.6 + 0.6 2-24** 10-38** 9.48** 5- 37 5-0 + 0-8 5-1 0.3 6-4 + 0-4 0.71 9.52** 15-82** 6- 48 5-1 ± 0.5 5.2 + 0-4 6.6 ± 0.5 1.08 14.70** 15-lS** 7- 48 5-2 +07 5-3 +0.7 6-6 + -5 0.86 11-28** 14-07** 8- 52 54 +06 54 +04 6-8 +0-6 0.00 11.90** 14.00** 9- 48 5.5 + 0-5 58 + 0-4 7.1 + 0.6 3-25* 14-19** 12-49** 10- 46 5-7 + 0-6 6-0 + 0-4 7-3 + 0-6 2-82* 12-79** 12-23** *Significant difference (P<0.05); **highly significant difference (P<0-001). Arch Dis Child: first published as 10.1136/adc.53.7.585 on 1 July 1978. Downloaded from

Position of the apex beat in childhood 587 although the mean distances of the AB in the erect 100 position were consistently higher than the corresponding values in the supine position, the differences 90; were not significant except at the age of 10 years. 0 The normal distance in centimetres of the AB from the midline may be obtained for children aged ~70 between one and 10 years, using an age formula 0- 60 (AB = 3 * 8 + 0 * 2 x age in years). Table 3 compares o-@ 4th space 41 50 o--a 5th space the measured mean apical distances for every year of 40 life with the expected mean distances using the above formula. Lo-30 The position of the AB in relation to the ICS is a. a shown in Table 4. The AB was in the 4LICS in all 20 the 61 subjects from birth to 3 years. Among 14 children aged 4 years, the AB was in the 4LICS in 8 10I (57%) and in the 5LICS in 6 (43 %), while in 37 0 children aged 5 years, it was in the 4LICS in 29 <4 4 5 6 7 8 9 10 (78%), and in the 5LICS in 8 (22%). Thereafter, Age (years) with increasing age the AB gradually moved into Fig. 2 Position of the apex beat in relation to the the 5LICS so that at the age of 10 years it was in the intercostal spaces. The apex beat was in the 4LICS in 5LICS in 37 (81 %) of 46 subjects. Fig. 2 shows the all the subjects below the age of4 years. age at which transition of the AB from the 4LICS to the 5LICS occurred. It must be noted however, that there were few children in the age group 5-10 years in whom the AB could still be located in the 4LICS. Table 5 summarises the correlation between the Table 3 Mean distance of the apex beat (AB) and distance of the AB in the erect position and the chest predicted mean apical distance from the first birth day circumference. In all the age groups the correlations using the formula (AB = 3- 8 + 0-2 x age) were generally poor, the values ranging between 0 *08 7-9 were Age (years) AB distance (cm) from the ML and 0 37. The correlations for ages years nevertheless significant (P<0 *05). However, for all. http://adc.bmj.com/ Measured mean Predicted mean ages together the correlation was much higher 1- 3-8 4-0 (r = 0-61, P<0 001). 2- 4-1 4-3 3- 4-7 4.4 4- 4-6 4-6 Discussion 5- 5-0 4.8 6- 5.1 5-0 to Dressler the position of the 7- 5.2 5.2 According (1959), 8- 5.4 5.4 apex beat in childhood varies with age as well as with 9- 5-5 5-6 various physiological factors which cause a shift of on September 30, 2021 by guest. Protected copyright. 10- 5-7 5.8 the apical portion of the left ventricle towards the

Table 5 Correlation between the distance of the apex Table 4 Position ofapex beat in relation to the beat from the midline in erect position and the chest intercostal spaces according to age circumference for both sexes Age (years) No. and % of cases Age (years) No. of subjects r P 4LICS 5LICS 1- 11 0-23 >0-1 2- 17 0-32 >0-1 No. % No. % 3- 11 0.35 >0.1 4- 14 -0-08 >0-1 Birth-3 61 1000 - - 5- 37 0-30 >0-05 4- 8 57.1 6 42-9 6- 48 0.19 >0-01 5- 29 78.4 8 21-6 7- 48 0-37 =0-01* 6- 28 58.4 20 41.6 8- 52 0-33 <0-02* 7- 28 58.3 20 41.7 9- 48 0-34 =0-02* 8- 17 32.7 35 67.3 10- 46 0-25 >0-05 9- 10 20-9 38 79.2 10- 9 19.5 37 80-5 All ages 333 0.61 <0.001* correlation. LICS = left intercostal space. *Significant positive Arch Dis Child: first published as 10.1136/adc.53.7.585 on 1 July 1978. Downloaded from

588 Antia, Maxwell, Gough, and Ayeni chest wall. The predominating pulsatory movement beat in the supine position from the midline in of the thoracic wall under physiological conditions normal children from birth to the age of 10 years giving rise to the apex beat is the systolic thrust of varies between 2 8 and 5 4 cm. (b) The MCL as a the lower third of the frontal aspect of the left reference point in relation to the AB is not an ventricle towards the anterior wall of the thorax. accurate index of normal cardiac size for children Since the thickness of the left ventricular wall of all ages. However, compared with the NPL it is increases with age (Cruz et al., 1960) the position of a better reference point for estimating normal cardiac the apex beat in childhood in relation to the MCL, size. (c) The NPL is of no value in assessing normal NPL, and ICS would be expected to change with cardiac size. It should therefore not be used in age, as well as the chest circumference. clinical practice. (d) Under the age of 4 years the AB The above facts seem not to have been taken into is normally in the 4LICS; between 4 and 7 years it consideration when White (1951) and Dammann may be found in either the 4 or 5LICS; thereafter (1959) stated that the apex beat was in the 4LICS in it is located in the 5LICS in most children. normal children of all ages. Indeed, the latter author From these conclusions it is recommended that in went on to state that 'when the apex beat is felt in clinical practice the evaluation of normal cardiac the SLICS in childhood the probability of left size in children should be carried out by actual ventricular enlargment must be entertained'. Simi- measurement of the AB from the midline. From the larly to state that the apex beat in normal children first birthday onwards the AB is about 3*8 cm plus of all ages is in the SLICS, as asserted by Julian 0 * 2 cm for every year of age. (1970) and by Julian and Turner (1974), ignores the expected progressive increase of the left ventricular wall which takes place throughout childhood. We thank the Commonwealth Secretariat, London, The study has shown that the traditional use of the whose grant enabled A.U.A. to visit the University MCL and NPL as reference points in relation to the of the West Indies; Dr Michael Lowry, Department AB is not an accurate index of normal cardiac size. of Paediatrics, University of the West Indies, for his At some ages (1 and 3 years) the mean distance of co-operation and suggestions; Dr M. T. Ashcroft, the MCL was less (P<0 05) than that of the AB, Epidemiology Research Unit, Medical Research while in others (4, 9, and 10 years) this mean distance Council, University of the West Indies, for valuable was greater (P<0 05) than that of the AB. In other suggestions as well as for lending to us a weight the AB is within the MCL in neonates, scale/stadiometer; the respective headmasters and words, teachers of Mona Primary School and the Hope infants, and other children up to the age of 3 years, http://adc.bmj.com/ while it is outside this line in most older children. Valley Experimental School and the principal, Day- Furthermore the position of the NPL in relation to Care Nursery, University of the West Indies, for the AB was well outside the AB in children of all their co-operation; the parents for allowing their ages, the mean distance ofthe NPL being consistently children to participate in the studies. greater (P<0 001) than that of the AB. With regard to the position of the AB in relation to the intercostal spaces, the study also shows that References it is incorrect to assert that the AB is in the 4LICS on September 30, 2021 by guest. Protected copyright. in all children from birth to the age of 2 years and Cruz, M. V. de la, Auselmi, G., Romero, A., and Monroy, G. thereafter in the 5LICS (Kaplan, 1975), or that it is in (1960). A qualitative and quantitative study ofthe ventricles in ages (Julian, 1970; and great vessels of normal children. American Heart the SLICS children of all Journal., 60, 675-690. Julian and Turner, 1974). The present study shows Dammann, J. F., Jr (1959). Clinical aspects of congenital that in all children up to the age of 3 years the AB heart disease. In Cardiology, volume 3, pp. 6:36-6:80. is in the 4LICS. In 57, 78, 58, and 58% of children Edited by A. A. Luisada. McGraw-Hill: New York. 7 years the was Dressier, W. (1959). Clinical evaluation of pulsations of the aged 4, 5, 6, and respectively, AB chest wall. In Cardiology, volume 2, pp. 3:56-3:63. still present in the 4LICS, but from the age of 8 to Edited by A. A. Luisada. McGraw-Hill: New York. 10 years it was in the 4LICS in only 25 %. Julian D. G. (1970). The venous pulse: palpation of the A direct correlation was found between the heart. In Cardiology, second edition, p. 105. Bailliere, distance of the AB and the chest circumference in Tindall: London. Julian, D. G., and Turner, R. W. D. (1974). Examination of the age group 7-9 years and not in the younger age the heart. In Davidson's Principles andPractice ofMedicine, groups. This may be explained by the fact that in eleventh edition, pp. 210-214. Edited by J. Macleod. children below the age of 7 years the chest circum- Churchill Livingstone: Edinburgh. ference was perhaps not measured in full inspiration. Kaplan, S. (1975). The heart and circulation in health and disease. In Nelson Textbook of Paediatrics, tenth edition, From the present study the following conclusions pp. 1000-1017. Edited by V. C. Vaughan and R. J. Mckay. can be drawn. (a) The mean distance of the apex Saunders: Philadelphia. Arch Dis Child: first published as 10.1136/adc.53.7.585 on 1 July 1978. Downloaded from

Position of the apex beat in childhood 589 Keith, J. D., Rowe, R. D., and Vlad, P. (1967). Heart Disease White, P. D. (1951). Physical examination of the heart itself. in Infancy and Childhood, second edition. MacMillan: In Heart Disease, pp. 66-68, fourth edition. Macmillan: New York. New York. Nadas, A. S. (1963). Pediatric Cardiology, second edition. Saunders: Philadelphia. Taussig, H. B. (1960). Congenital Malformations ofthe Heart, second edition, volume 1. Harvard University Press: to Professor A. U. Antia, Depart- Cambridge, Mass. Correspondence Watson, H. (1968). Paediatric Cardiology, first edition. ment of Paediatrics, University of Ibadan, Ibadan, Lloyd-Luke: London. Nigeria.

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