Sir.—We read with great interest the article by Sondheimer and colleagues1 concerning unequal cardiac care for children with Down's syndrome. The authors discussed a variety of reasons for late referrals, but their comment that "all children with Down's syndrome, even those without an audible heart murmur, should have a pediatric cardiology evaluation some time in the first nine months of life" needs to be stressed and, in our opinion, amended.
Several years ago, we examined 71 patients with Down's syndrome, aged 5 months to 15 years, who did not have any clinical manifestations of cardiac disease. No heart murmurs were heard by their pediatricians or pediatric cardiologists. An electrocardiogram and chest x-ray film examination were routinely performed on all of these patients. Seven (10%) of the patients who did not have any manifestations of cardiac disease had an abnormal electrocardiogram and/or chest x-ray film associated with significant