Heart Failure In Children

Introduction:

Heart failure is a clinical syndrome in which the heart is unable to pump enough blood to meet the metabolic demands of the body despite adequate atrial filling.

Causes

Unlike adults, the most common causes
of heart failure in children are:

Non-cardiac causes including

  • Pneumonia
  • Severe anaemia

In neonates, metabolic factors such as:

  • hypoglycemia
  • hypoxia and
  • acidosis

Acquired heart diseases especially
rheumatic heart diseases and cardiomyopathies.

Clinical features:

  • Breathlessness
  • Cough
  • Sweating on feeding (diaphoresis especially on feeding)
  • Feeding difficulty: ‘suck-rest-suck cycle’ as a result of effort dyspnoea
  • Poor weight gain/Failure to thrive
  • Pedal or facial swelling
  • Features of underlying disease

Note! Cardinal signs for the diagnosis of heart failure in children are tachypnoea, tachycardia, tender hepatomegaly, ┬▒cardiomegaly

Investigations:

  • Chest X-ray,
  • ECG,
  • Echocardiography,
  • Cardiac catheterization.
  • Electrolyte, urea and creatinine
  • Packed cell volume
  • Others-depending on the cause

Treatment Objectives

  • Decrease preload
  • Relieve symptoms of pulmonary and systemic venous congestion.
  • Increases myocardial contractility

Drug treatment:

1. Diuretics:

  • Frusemide (1-2mg/Kg/day),
  • Spironolactone (1-2mg/Kg/day)

2. Inotropes:

  • Digoxin

Dosage regimen of digoxin)

Age*Digitalization (mg/kg/day)Maintenance (mg/kg/day)
<1 month0.04-0.060.01
1 month - 2 years.0.04-0.080.01-0.02
>2 years0.04-0.060.01
Adult0.05-1.0 (mg/day)0.25-0.5 (mg/day)

How to Digitalise: give half the total digitalizing dose (TDD) immediately, followed by 4 and then the final 4 of the TDD at 6-8hour intervals.
Maintenance dose: Start maintenance dose 12hours after the final TDD.
Maintenance dose is 25% of TDD
Other inotropes: Dopamine and Dobutamine in ICU or high dependent unit

3. ACE inhibitors:

Captopril, Enalapril (in patients with Left to right shunts: (VSD, PDA, left sided
regurgitatant lesions (mitral or aortic
regurgitations) or poor systolic function
(dilated cardiomyopathy, myocarditis)

4. Beta-blockers:

Carvidilol in chronic heart failure
Dilated cardiomyopathy

Non-drug treatment:

  • Bed rest-reduces demand on the heart
  • Oxygen therapy
  • Nurse in prop up (Cardiac) position
  • Correct acidosis
  • Nutritional rehabilitation- ensure adequate caloric intake, give frequent small feeds
  • Salt restriction in form of low salt formula not recommended in infants
  • Treatment of underlying cause
  • Blood transfusion-for anaemia,
  • Antibiotics for pneumonia
  • Surgical repair of congenital heart defects.

Notable Adverse Reactions