This document discusses congestive cardiac failure in infants and children. It describes the causes, signs, and management of cardiac failure. The main causes in infants include congenital heart disease, arrhythmias like supraventricular tachycardia, and myocarditis. Signs of left-sided failure include tachypnea and hepatomegaly while signs of right-sided failure include hepatomegaly and facial edema. Management involves reducing cardiac workload, improving contractility, and treating the underlying cause. Diuretics, vasodilators, inotropes, and drugs that suppress the renin-angiotensin system are used. Prognosis depends on the cause, with mortality from cardiac failure being high

1. G.ERIC™ MD4

2. Congestive cardiac failure is the inability of the
heart to
maintain an output, at rest or during stress,
necessary
for the metabolic needs of the body (systolic
failure) and
inability to receive blood into the ventricular
cavities at
low pressure during diastole (diastolic failure).

3. An increase in left sided pressures results in
dyspnea from
pulmonary congestion. An increase in right
sided
pressures results in hepatomegaly and edema.

4. Rheumatic fever
and rheumatic heart disease is typically encountered
beyond 5 yr age; its prevalence appears to be declining
in
selected urban populations. Heart failure from
congenital heart disease typically
happens within the first 1-2 yr of life. Patients with left
to
right shunts tend to develop CCF around six to eight
weeks of life. Heart failure from congenital heart
disease typically
happens within the first 1-2 yr of life. Patients with left
to
right shunts tend to develop CCF around six to eight
weeks of life.

5. Arrhythmias are an important cause of
congestive
cardiac failure in infancy. Three-quarters of
infants with
paroxysmal supraventricular tachycardia are
below
4 months old. Heart rates above 180/min tend
to precipitate
heart failure. If the tachycardia persists for 36
hr, about 20% will
develop heart failure and almost 50% will do so
in 48 hr.

6. Infants
 Congenital heart disease
 Myocarditis and primary myocardial disease
 Tachyarhythmias, bradyarhythmias
 Kawasaki disease with coronary occlusion
 Pulmonary hypertension (persistent
pulmonary hypertension
 of the newborn; primary pulmonary
hypertension; hypoxia,
 e.g. upper airway obstruction)

7. Miscellaneous causes
 Anemia
 Hypoglycemia
 Infections
 Hypocalcemia
 Neonatal asphyxia (myocardial dysfunction,
pulmonary
 hypertension)

8. Children
 Rheumatic fever, rheumatic heart disease
 Congenital heart disease complicated by
anemia, infection or
 endocarditis
 Systemic hypertension
 Myocarditis, primary myocardial disease
 Pulmonary hypertension (primary, secondary)

9. The recognition of cardiac failure in older children is
based
on the same features as in adults.
Symptoms. Slow weight gain is related to two factors.
The
infant takes small feeds because of easy fatigability
and
there is an excessive loss of calories from increased
work
of breathing. Uncommonly, there may be an unusual
gain
in weight due to collection of water, manifesting as
facial
puffiness or rarely as edema on the feet.

10. Often a mother may state that
the baby breathes too fast while feeding or
that the baby
is more comfortable and breathes better when
held against
the shoulder-which is the equivalent of
orthopnea in
older children. Not infrequently, the baby is
brought with
persistent hoarse crying, wheezing, excessive
perspiration
and less commonly, because of facial puffiness

11. Signs. Left sided failure is indicated by
tachypnea and
tachycardia. Persistent cough, especially on
lying down,
hoarse cry and wheezing are other evidences
of left sided
failure; basal rales in the chest are usually not
audible.

12. Right-sided failure is indicated by hepatomegaly and
facial
puffiness. Examination of the neck veins in small babies
is not helpful. Firstly, it is difficult to evaluate the short
neck with baby fat and secondly, hemodynamic studies
show that right atrial mean pressures stays normal in
more
than one-half of infants with congestive failure. Edema
on the feet occurs late. Common to both left and right
sided
failure is the presence of cardiac enlargement, third
sound
gallop and poor peripheral pulses with or without
cyanosis

13. Left sided failure
 Tachypnea
 Tachycardia
 Cough
 Wheezing
 Rales in chest
Right-sided failure
 Hepatomegaly
 Facial edema
 Jugular venous
 engorgement
 Pedal edema
Failure of either side
 Cardiac enlargement
 Gallop rhythm (S3)
 Peripheral cyanosis
 Small volume pulse
 Lack of weight gain

14. Management of heart failure is a four-pronged
approach
for correction of inadequate cardiac output. The
fourprongs
are: (i) reducing cardiac work, (ii) augmenting
myocardial contractility, (iii) improving cardiac
performance,
(iv) correcting the underlying cause
Identification
of the cause is important since it has direct
bearing on survival.

15. The work of the heart is reduced by restricting
patient
activities, sedatives, treatment of fever,
anemia, obesity, and by
vasodilators. Mechanical ventilation helps
when heart failure
is severe by eliminating the work of breathing.

16. Neonates with heart failure are nursed in an incubator.
They are handled minimally. The baby is kept propped
up at an incline of about 30
°
. The pooling of edema fluid
in the dependent areas reduces the collection of fluid
in
lungs, thus reducing the work of breathing. At a
temperature of 36-37
°
C, the overall circulatory and
metabolic needs are minimal, thus reducing work of
heart.

17. If the infant or the child is restless or dyspneic,
sedatives
are used. Morphine sulfate in doses of 0.05 mg/kg
SC
provides effective sedation. A benzodiazepine such
as
midazolam is useful for sedation in selected
circumstances.
Sedatives reduce anxiety and lower the
catecholamine
secretion, thus reducing physical activity,
respiratory and
heart rate. Requirement of oxygen for body tissues
goes
down, and this reduces the cardiac workload.

18. Fever, anemia or infection also increase the
work of the
heart. In infants and smaller children the
presence of
superadded pulmonary infection is difficult to
recognize.
Antibiotics are therefore, sometimes
administered
empirically. In older children antibiotics are
used, only if
evidence of infection is present

19. Anemia imposes stress on the heart because of the
decreased oxygen carrying capacity of blood. Anemia
results in tachycardia and in a hyperkinetic circulatory
state. Correction of anemia will result in decreased
cardiac
work. If transfusion is indicated packed red cells can be
administered. Typically packed cell volumes of 10-20
ml/
kg are required to correct severe anemia; a single dose
of
frusemide IV is often given prior to the transfusion. Less
common conditions causing stress to the heart are
repeated
pulmonary emboli, thyrotoxicosis and obesity.

20. Vasodilators counteract the compensatory
mechanisms in
heart failure and improve cardiac
outputArteriolar and venous vasoconstriction
is mediated through
catecholamines. Arteriolar constriction
maintains blood
pressure by increasing the systemic vascular
resistance,
which increases the work of heart. Nitrates are
used as preferential venodilators and
hydralazine as an arteriolar
dilator.

21. ACE inhibitors (captopril, enalapril) are effective for
treating heart failure in infants and children. These
agents
are effective vasodilators, suppress renin-
angiotensinaldosterone
system, reducing vasoconstriction and salt
and water retention. By suppressing catecholamines,
they
prevent arrhythmias and other adverse effects on the
myocardium. The major side effect of ACE inhibitors is
cough, which can be troublesome. Persistent cough may
necessitate the use of angiotensin receptor blockers,
such
as losartan.

22. Initially it is necessary to monitor the renal
function: urinalysis, blood levels of creatinine
and electrolytes
once a week for six to eight weeks. These
medications
may cause first-dose hypotension; the first
dose should
be one-quarter of the calculated dose. The
patient should
ideally remain recumbent for the first 6 hr to
prevent an
unusual fall in blood pressure.

23. Although beta-blockers might precipitate CCF, they
improve symptoms and survival especially in patients
with dilated cardiomyopathy, who continue to have
tachycardia.
Useful agents include metoprolol and carvedilol.
The latter is preferred since it has properties of
betablockers
with peripheral vasodilation; treatment is started
at low dose and increased depending on tolerability
(0.08
to 0.4 mg/kg/day, maximum 1.0 mg/kg/day). Calcium
channel blockers have adverse effects in heart failure
and
should be avoided unless indicated for systemic
hypertension.

24. In the acute care setting, sodium nitroprusside is
used as
a vasodilator, since it acts on the venous and
arterial systems. These
agents have powerful vasodilatory and inotropic
effects.
Specific indications for use of vasodilators include
acute
mitral or aortic regurgitation, ventricular
dysfunction
resulting from myocarditis, anomalous coronary
artery from
pulmonary artery and in the early post operative
setting.

25. Augmenting myocardial contractility by inotropic agents
like digitalis improves cardiac output. In infants and
children, only digoxin is used. It has a rapid onset of action
and is eliminated quickly. It is available for oral and
parenteral administration. Oral digoxin is available as 0.25
mg tablets and as digoxin elixir (1 ml = 0.05 mg) (Table
15.6). Parenteral digoxin (0.5 mg/2 ml) is available; its dose
is 70% of the oral dose. Infants tolerate digitalis well. In a
hospitalized patient
full digitalization should be sought to maximize benefit.
Children are digitalized within a 24 hr period; 1h of the
calculated digitalizing dose is given initially, followed by
% in 6-8 hr and the final % after another 6-8 hr. The
maintenance dose is usually one-quarter of the digitalizing
dose

26. Before the third daily dose, an
electrocardiogram is done to rule out digitalis toxicity.
Toxicity can be controlled by omitting the next one or two
doses. Digitalis is used with caution in the following
situations:
(i) premature neonates; (ii) heart failure due to myocarditis;
and (iii) very cyanotic patients. In other situations, it is
better to use half the calculated digitalizing and the
maintenance
dose initially. Myocardial damage, gross cardiomegaly,
hypoxia, acidosis, hepatic, renal and pulmonary
insufficiency increase the sensitivity of the myocardium to
digitalis. Digoxin is beneficial for symptom relief and is
advised in patients with mild, moderately severe or severe
congestive failure, with or without sinus rhythm. Digoxin
can be combined with ACE inhibitors for synergistic effect.
By increasing cardiac output, digoxin lowers systemic
impedance indirectly, unloading the ventricles

27. These agents belong to two groups: (i) catecholamine
inotropes, like dopamine, dobutamine and adrenaline and
(ii) phosphodiesterase inhibitors like amrinone and
milrinone. These agents combine inotropic effects with
peripheral vasodilation. If blood pressure is low, dopamine should be
used, as an intravenous infusion. At a dose
of less than 5 microgram/kg per minute, dopamine causes
peripheral vasodilation and increases myocardial
contractility. Renal blood flow improves, resulting in
natriuresis; higher doses result in peripheral vasoconstriction.
The dose of dobutamine is 2.5 to 15 microgram/
kg/ min; the dose should be increased gradually
until the desired response is achieved. In patients with
dilated cardiomyopathy, dobutamine is used as 24 hr
infusion once or twice a week and retains its effectiveness
for varying lengths of time.

28. Diuretics reduce the blood volume, decrease venous
return and ventricular filling. This tends to reduce the
heart size. The larger the heart, the more the wall
tension
and the poorer is its performance. With reduction in
heart
size and volume, the myocardial function and the
cardiac
output improve. Diuretics reduce the total body sodium
thereby, reducing blood pressure and peripheral
vascular
resistance. This helps in increasing the cardiac output
and
reducing the work of the heart.

29. Diuretics are the first line of management in congestive
failure. The action of oral frusemide starts within 20
min.
Frusemide should be used in combination with a
potassium sparing diuretic (triamterene,
spironolactone,
amiloride) instead of using potassium supplements. The
combination prevent potassium and magnesium loss and
reduces the risk of arrhythmias. Frusemide activates
the
renin angiotensin aldosterone axis, which is responsible
for vasoconstriction and sodium and water retention.
When frusemide is combined with ACE inhibitors, the
combination suppresses the axis and is therefore
synergistic.

30. The other method of altering the body fluid volume is
by restricting the sodium intake. Sodium restriction is
difficult to implement in infants and young children.
Low
sodium diets should be used only if the heart failure
cannot
be controlled with digitalis, diuretics and ACE
inhibitors.
However, it is prudent to advise such patients to avoid
salt rich foods such as chips and pickles. Since heart
failure
increases calorie requirements, adequate intakes is
advised.

31. Digitalizing
dose, mg/kg
Maintenance
(fraction of
digitalizing dose)
Digoxin
Premature, neonates
1 month to one year
1 to 3 yr
Above 3 yr
0.04
0.08
0.06
0.04
1/4
1/3to1/4
1/3to1/4
1/3
Diuretics
Frusemide
Spironolactone
1-3 mg/kg per day
orally or
1 mg/kg per dose IV
1 mg/kg orally every 12
hr

32. Prognosis
The mortality of CCF in children is high and
prognosis
depends on the underlying cause.