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Heart Failure in children: Causes, Clinical Features, Management

Heart failure in children
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Heart Failure in Children, previously referred to as congestive cardiac failure (CCF), occurs when the heart is unable to pump blood adequately to meet the circulatory or metabolic needs of the body. HF can be categorized into systolic failure, where the heart fails to maintain an output necessary for the body’s metabolic needs at rest or during stress, and diastolic failure, which involves the failure to receive blood into the ventricles during diastole.

Causes of Congestive Heart Failure in Children

Congestive Heart Failure in children can have various causes, including cardiac and non-cardiac factors.
  • Cardiac causes may include congenital heart diseases such as:
    • Ventricular septal defect (VSD)
    • Transposition of the great arteries (TGA)
    • Total anomalous pulmonary venous drainage (TAPVD)
    • Patent ductus arteriosus (PDA)
    • Coarctation of the aorta (CoA)
  • Cardiac causes may include acquired heart diseases like:
    • Valvular heart diseases (e.g., mitral, aortic)
    • Infective endocarditis
    • Hypertensive heart diseases (e.g., acute glomerulonephritis)
    • Viral myocarditis, etc., can also contribute to heart failure.
  • Non-cardiac causes may include:
    • Fluid overload
    • Septicemia
    • Asphyxial cardiomyopathy
    • Severe anemia
    • Beriberi (wet), and thyrotoxicosis.

Clinical Features HF in Child

In infants
  • Irritability/excessive crying
  • Excessive sweating
  • Poor or difficult feeding
  • Respiratory distress, and wheezing
  • Edema, usually involving the eyes, sacrum, legs, and feet, may also be present.
In Children
  • Experience effort intolerance.
  • Dyspnea on exertion or at rest
  • Excessive sweating, cough, and abdominal pain, along with poor weight gain.
  • Other signs may include tachycardia, raised jugular venous pressure (JVP), hepatomegaly, bilateral basal crepitations, oedema, peripheral cyanosis, and a gallop rhythm.

Investigations of HF in Child

  • Diagnostic tests such as chest X-ray are used to assess cardiac size, pulmonary congestion, exclude pulmonary causes, detect congenital heart diseases, and determine an increased cardiothoracic ratio.
  • Electrocardiography may show nonspecific T and ST segment changes, tall P wave, and specific patterns of congenital and acquired heart diseases.
  • Echocardiography is used to assess structural pathology
  • Other tests such as hemograms, serum electrolytes, blood gas analyses, renal function tests, and blood cultures may also be performed.

Treatment of CHF

The goals of treatment for heart failure include:
  • Reducing cardiac work
  • Increasing myocardial contractility
  • Reducing cardiac size to improve performance
  • Treating the underlying cause

General measures

  • Patient in an upright position
  • Administering humidified oxygen via head box, mask, or nasal prongs
  • Bed rest and restriction of physical activities
  • Maintenance of body temperature
  • Feeding with breast milk or nasogastric tube feeding of foods rich in calories and low in sodium.

Reducing cardiac work

  • Bed rest: propped up at an angle of 30–45°
  • Restriction of physical activities
  • Sedation:
    • Morphine (0.5 mg/kg subcutaneously)
    • Benzodiazepine (midazolam, diazepam), phenobarbital, chloral hydrate or promethazine
  • Oxygen and Antibiotics
  • Correction of anemia
  • Vasodilators: nitroglycerine and nitroprusside

Augmenting myocardial contractility by inotropic agents

  • Digoxin: Total digitalization dose: 0.02-0.04 mg/kg
  • Sympathomimetic amines e.g. Dopamine, Dobutamine
  • Phosphodiesterase inhibitors e.g. Bipyridines, Amrinone and Milrinone, xamoterol, flosequinan

Reducing cardiac size to improve its performance

  • Digoxin
  • Diuretics e.g. Frusemide (1–3 mg/kg orally and 0.5–1.5 mg/kg parenterally) + K sparing diuretics e.g. spironolactone, amiloride
  • ACE inhibitors e.g. Captopril, Enalapril, to reduce the impedance to left ventricular ejection Restrict sodium intake

Correction of the Underlying Cause

  • Investigation like Echo
  • Definitive, palliative care

Stepwise Management of Pediatric Heart Failure

  • Step 1: Diuretics (frusemide) improve cardiac performance by reducing blood volume, and peripheral vascular resistance, and increasing cardiac output.
  • Step 2: Digoxin improves cardiac contractility through its inotropic action, reduces cardiac work, and decreases cardiac size.
  • Step 3: Angiotensin-converting enzyme inhibitors (captopril, enalapril) are administered with the withdrawal of potassium-sparing diuretics or supplementary potassium in conjunction with other diuretics.
  • Step 4: Vasodilators, preferably nitrates such as isosorbide dinitrate (oral) or sodium nitroprusside (IV), are used.
  • Step 5: Intermittent IV dopamine or dobutamine is administered.
  • Step 6: Beta-blockers (propranolol) or steroids are considered if active myocarditis is present.
  • Step 7: Heart transplantation may be considered a last resort.

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