Precordial Auscultation of the Heart of School Children in a Remote Sotang Village of Nepal

Precordial auscultation of the heart of children in a geographically difficult place of Nepal may be a remote dream of a pediatric cardiologist, and an unexpected opportunity for the children living in such places. While visiting my birthplace after 47 years, I planned a very brief visit to a basic school to auscultate the hearts of children to find out the condition of the heart in the shortest possible time by non-invasive clinical means, precordial auscultation. The auscultation of heart sounds is an important clinical parameter, specifically in resource-limited or remote areas of Nepal. Abnormal heart sounds such as murmurs are fairly common in children and adolescents. (1,2,3) Recently published materials have also utilized artificial intelligence-driven resources to detect cardiac murmurs in resource-limited circumstances. (4)

I visited the school located in Shivatar, Sotang rural municipality of Solukhumbu district, Nepal, in May 2026. The place is quite remote since it can be reached only after passing through a lot of harsh mountainous terrain and having to cross the forceful Dudhkoshi river. It took 20 hours by 4-wheel Jeep drive (Sumo) from Kathmandu to Sotang (about 300 km). This beautiful village is inhabited by a diverse and multicultural community. Considering the limitations of time, basic information about the school from the headmaster was obtained before starting the trip.

Prompt clinical assessment of the hearts of children in the field was done by appropriate auscultation of the precordium, axilla and back, along with pulse oximetry when needed. A one-day heart screening test by auscultation of all children attending ‘early childhood development’ (ECD) groups to grade VIII students was performed in a basic school on May 4, 2026. It was the first day of the academic session of the school, hence a slightly low number of students attended the classes. A brief orientation was done to the involved teachers before starting the auscultation. Teachers helped with verifying the students, managing the children for examination, and recording the data. I utilized a non-invasive, portable 3M Littmann Cardiology IV Stethoscope for auscultation, and oximetry, and sphygmomanometer when necessary. I carefully and attentively auscultated the precordium of each child in one of the quiet and well-lit school classrooms. Auscultation was done by placing the child in a sitting position (as seen in the photograph). The precise auscultate time of 228 children by a lone pediatric cardiologist was 3 hours 40 minutes, an average of 58 seconds for a child. This was the first time that a pediatric cardiologist had auscultated the hearts of children in that school.

A total of 228 children of an ECD and basic school were involved in the screening. The age ranged from 28 days to 17 years. The youngest child auscultated on the day was a 28-day-old baby, a sibling of one of the students rushed by her mother for cardiac evaluation. A slightly more female children were observed on the day. (Table 1) Almost 90% of the children had normal auscultatory findings. Innocent murmurs were heard in 17 children (7.46%), predominantly in males. Innocent murmurs are systolic, of short duration, and usually soft and blowing; occasionally they are loud and harsh. The findings of the auscultation are shown in Table 2. The grade II to III systolic murmurs at the left sternal border (LSB) were audible in 3 children (2 males and a female). They were attending regular classes, but one of the male students complained of easy fatigability while climbing on the way up returning to his house. Only children with additional heart sounds or murmurs were evaluated by oximetry, and found normal oxygen saturation in all children at rest.

The three children (systolic murmur >grade II) suspected of some heart abnormalities were counseled to refer to Kathmandu for echocardiography in a national heart center, not to wait for a long time. Moreover, children with innocent murmurs may be a concern for many guardians and physicians, and they may need further evaluation without a hurry. The results of the survey were shared with the headmaster and the guardians. They were counseled about the results and possible outcomes.

 Auscultation along with pulse oximetry can be helpful in early clinical recognition, and referral of children with significant heart murmurs. Counseling is of paramount importance for children with murmurs, since there may be therapeutic, familial, financial and transportation concerns for the parents and families living in resource-stricken and remote communities like Sotang, at lower Solukhumbu region.

 Precordial auscultation along with teacher-guardian’s observation of students’ physical conditions helps to identify the severity and magnitude of heart health problems among basic school children. Further evaluation of the hearts of children by pediatric cardiac echocardiography enhances scrutinizing of hearts of children in remote places.

Acknowledgment
I would like to acknowledge the help provided by the headmaster of Shree Birendra Jyoti High School, Sotang, Mr. Motiram Basnet. I would also like to express gratitude to the involved school teachers, guardians and school team for effective management of the survey at very short notice.

References 
1.  Frank JE, Jacob KM. Evaluation and management of heart murmurs in children. Am FAM Physician. 2011 Oct 01;84(7):793-800.
2.  O’Meara D. Evaluation of heart murmurs in children. JAMA Pediatr 2023;117;(8):874. Accessed on May 15, 2026 https://jamanetwork.com/journals/jamapediatrics/fullarticle/2806207#249164747
3.  Meija E, Duper S. Innocent murmur. Last update: Sep 4, 2023. Accessed on May 15, 2026; https://www.ncbi.nlm.nih.gov/books/NBK507849
4.  Zolya MA, Popa EL, Baltag C, Bratu DV, Comon S, Mororu SA. AI-Enhanced Detection of Heart Murmurs: Advancing Non-Invasive Cardiovascular Diagnostics. Sensors (Basel). 2025 Mar 8;25(6):1682. Accessed on May 30, 2026.
 https://pmc.ncbi.nlm.nih.gov/articles/PMC11945174/  

Table 1. Age and gender distribution of students undergone heart auscultation in a basic school in Sotang, Solukhumbu, Nepal (n=228).

Table 2. Auscultatory findings of students of Birendra Jyoti High School Sotang, Solukhumbu, 2026 (n=228).

LSB, Left sternal border