Common Causes of Heart Failure in pediatrics
Congenital Heart Disease = 40 %
Rheumatic Heart Disease = 20-25 %
Myocarditis = 30 %
Clinical Presentations
Clinical picture is usually different in different age groups. It is better
to divide age groups as follows.
Neonates: Upton 1 month of age
Infants: From 1 month to 1 year
Children: 1-5 years old
Children: 5-12 years old
Most important points to remember
Murmurs: Concept of associating the possibility of heart failure with the
presence of cardiac murmurs must be discarded forcefully. In more than 50 % of
cases of heart failure there may not be any murmur. Whenever a murmur is
present, it should not be left unevaluated by a cardiologist.
Respiratory Difficulty: Differentiating of respiratory difficulty and
intercostals recession of chest wall in children suffering from heart failure
and lung conditions is simple. Children suffering from heart failure look well
and unaware of respiratory difficulty while those of lung disease look unwell
and quite conscious of breathlessness as it is of recent onset and it may be
associated with chest pain.
X-ray Chest in Children: Uphill 12 years of age it should be always AP view and
never PA view. This is a very common mistake. Heart size should be measured in
the full inspiratory films. Transverse diameter of cardiac shadow should be more
than 60 % of that of chest cavity, if it has to be labeled as enlarged.
ECG: ECG under one year of age does not reveal much information. So time should
not be wasted on ECG in children between 1-5 years old, only valuable finding
one can pick up is low voltage (<5mms) qrs complexes in Myocarditis.
Echocardiography: This is the basic investigation, in addition to x-ray chest
for the diagnosis and definition of heart failure in paediatric patients. But
someone who is experienced in paediatric echography must carry this out.
Tachycardia: This is single most important sign when counted at normal
temperature.
Gallop Rhythm: If you can imagine the sounds of hooves of horse running at full
speed smoothly,this is the gallop rhythm.This is again very important sign to
pick up in heart failure.
Tachycardia.What is normal heart rate?
This is most important sign in neonates & children presenting with heart
failure. Following rates, only with normal temperature, adjusted to age groups
should be referred to.
Tachycardia is present when rate is more than
160/m in neonates.
120/m in infants
100/m in children aged 1-5 years.
Presentations in Neonates
Usually there is no murmur.
Baby is not taking milk properly. He cannot suck for adequate period of time.
This leads to breathlessness so he has to discontinue.
He looks breathless even when not feeding. Respiratory rate is faster.
Sweating is visible. This is due to sympathetic over stimulation.
Sleep is impaired.
Signs of shock may be present. Cold clammy body, palor, cyanosis may be
present. Central cyanosis should not be missed and ignored. Peripheral cyanosis
may be due to low temperature of room or something but central cyanosis is
always due to disease.
Tachycardia along with gallop rhythm is always present.
Conscious level may be impaired.
Presentations in Infants
Congenital Heart Disease and heart failure may present with repeated chest
infections and anemia.
Cardiac murmur may be present or absent. There may be no murmur in more than
50 % of cases. Absent murmur is known as soft sign. In more than 90 % of
patients it is due to acute Myocarditis.
In patients of congenital heart disease murmur is invariably present. Gallop
rhythm indicates heart failure.
Pulse is usually low volume, feeble.
Feeding difficulties persist. Bottle-feeding with a wider bore in the nipple
may be easier to suck. Weaning from milk and introducing sold diet improves the
intake so overall health.
Sweating continues to be visible. Palor is there. Cold extremities can be
felt.
Child keeps on playing although his breathing is fast and in drawing of ribs
is visible when shirt is lifted.Subcostal and intercostal recession can be seen.
Anemia is usually present. Child fails to thrive.
Intellectual development is normal but fine motor developments,and so the mile
stones are delayed.
Presentations in 1-5 years old children
There may be no symptoms and signs of heart failure. Patients with congenital
heart disease are developing pulmonary hypertension during this period. That is
why this period is sometimes described as honeymoon period.
Heart Failure due to Acute Myocarditis (also in infants)
This is common in this age.30 % of cases of heart failure are due to acute
myocarditis. These are being missed. Majority of these get admitted in other
wards like Gasteroenterology (abdominal pain with hepatomegaly) or Chest
(Pneumonia) and later on shifted to cardiology ward.
Child usually presents as
Pale
Looks of being unwell
Sweating
Cold extremities
Tachycardia
No murmur but gallop rhythm is very typical and significant for diagnosis of
heart failure.
Due to severe dilatation of heart, pulse is usually low volume, feeble.
Tachypnoea.Subcostal recession but no intercostals recession.
Severe abdominal pain due to congested, enlarged & tender liver.
Acute Myocarditis is usually viral and secondary to viral upper respiratory or
gastrointestinal infections.
Symptoms like palor, sweating, and tachycardia are due to sympathetic over
stimulation in heart failure. These patients are not anaemic. Still many
patients keep on receiving blood transfusions against wrongly ascribed anaemia.
These transfusions make the child worse.
Presentations in 5-12 years old children
This generally resembles picture in adults.
Breathlessness on exertion
Palpitation/Tachycardia.
Murmurs
In left chest heave and apex beat may be visible. Cardiomegaly may be elicited
on examination.
Gallop rhythm is present.
Edema or Ascites may be present.
Child may fail to thrive.
Rheumatic Heart Disease is common in this age group.
History of prolonged fever is usually present. Or fever may still be present
Joint pains may be present.
Management of Acute Failure Heart
o Save an I/V line immediately.
o Give Oxygen.
o Lasix i/v, 1mg/kg immediately
o Do not give digoxin if patient is to be referred immediately to a
cardiologist. But if this baby has to be managed for few days then digoxin (in
addition to diuretics) can be given.
¼ tab in babies less than 1year old
¼ to ½ tab in patients weighing less than 25 kgs
1 tab in patients weighing more than 25 kgs.
o Mother’s milk should be given with a bottle and a wide bore nipple.
o Weaning should be started as soon as possible.
Fallot’s Tetrology
This is most common congenital heart disease after first month of age. It is
present in 70 % of patients.
~It almost never progresses to heart failure.
~Clubbing is a common feature.
~Cyanotic spells are present.
~Ejection systolic murmur is a feature.
~X-ray chest shows peripheral oligaemia and boot shaped heart.