Congenital Heart DiseasesCongenital Heart Diseases
CSN VittalCSN Vittal
Questions we face
1. Does the child have a heart
disease?
2. Is it congenital heart disease?
3. What type of lesion?
4. Wh...
CHD
• DEFINITION
– PRESENT AT BIRTH
• INCIDENCE
– 6-8 PER 1000 LIVE BIRTHS IN
WESTERN COUNTRIES
• ETIOLOGY
– IN MAJORITY N...
APPROACH TO CHD
• DOES THE PATIENT REALLY HAVE
CHD
• IS THE PATIENT CYANOTIC OR
ACYANOTIC
• IS PULM ARTERIAL BLOO FLOW
INC...
• HISTORY
– PRENATAL - DM,DRUG ABUSE,SLE
– INFANT - FEEDING DIFFICULTIES
• SYMPTOMS OF CHF
– POOR WEIGHT GAIN,DIFFICULTY I...
Approach to CHD
• Does the child have Heart Disease?
NADAS Criteria
MAJOR
1. Systolic murmur Gr. III or
> intensity
2. Dia...
Approach to CHD
• IS the Heart Disease Congenital?
CONGENITAL
1. Recognition early in age
2. Murmurs more
parasternally
3....
Approach to Heart disease
Cyanotic CHDAcyanotic CHD
Patient
Apply NADAS’ Criteria
Heart Disease Present Heart Disease Abse...
CHDs
Shunting
Stenotic R - > L L - > R Mixing
Aortic
Stenosis
Tetrology of
Fallot
Patent
ducturs
Truncus
Pulmonic
Stenosis...
Approach to CHD
• Is it Acyanotic or Cyanotic
CYANOTIC
1. Clinical cyanosis – Uniform or Differential
2. R/o. respiratory,...
Approach to CHD
• Pulmonary Blood Flow
Is it Normal / Increased / Decreased
INCREASED
1. Rec. respiratory infections
2. Cy...
Second Heart Sound S2
S2
A2 P2
Accentuated
Diminished
Delayed
Early
SH, AR
Calc.AV, Aortic Atresia
AS, PDA, AR, LVF, LBBB
...
Spliting of Second Heart Sound
Expiration InspirationSpliting
Normal
Wide & Variable
Paradoxical
Wide & Fixed
Single Secon...
Chief complaints
• Breathlessness
• Palpitation
• Chest pain
• Cough
• Edema
• Failure to thrive
• Joint pain / swelling
•...
History
• Gestational and natal history
– Infections, (Rubella in 1st
trimester, Mumps, CMV,
HSV, Coxsackie virus B)
– Mat...
History
• Postnatal history
– Weight gain
• Feeding pattern
– Prolonged feeding time with multiple interruptions
– Dyspnoe...
• Frequency of respiratory infections
– Rec. LRIs, Rec. wheezing or strider
• Joint symptoms
– Sore throat and joint sympt...
Physical Examination
• General examination
• Growth
• Respiration
• Excessive sweating
• Colour
– Cyanosis
– Pallor
– Jaun...
Pulse
• Peripheral pusles
– Lower limb pulses reduced in
coarctation of aorta
• Acyanosis with bradycardia
– AV canal defe...
JVP
• Prominent ‘a’ wave :
– Pulmonay stenosis
• Absent ‘a’ wave:
– Pulm. Hypertension due to L->R shunt
• V waves
– Tricu...
Signs & Symptoms of
Infective Endocarditis
• H/o CHD or any procedures
• Fever
• Chills
• Chest & abdominal pain
• Dyspnea...
Signs & Symptoms of PHT
• History of Congenital Heart
disease
• Breathlessness, fatigue, syncope
on exertion
• Chest pain
...
Signs & Symptoms of failure
• Feeding difficulty
• Hepatomegaly
• Edema on dependent parts
• Failure to thrive
• Feeding d...
CHDs
• Specific lesions
Ventricular Septal Defects
Type of VSD
Anatomic location is important with regard to chance of
spontaneous closure, surgical approach, risk of conduc...
Supracristal VSDs - Clinical
• Associated AI Murmur
• Systolic murmur heard over pulmonic area
that radiates to the Lt. cl...
Perimembranous - Supracristal
Muscular VSDs
• Representing 10% of isolated VSDs
• Completely surrounded by muscle
• May be in the
– inlet,
– trabecular,...
Muscular VSDs - Clinical
• High frequency systolic murmur which
ends prior to systole
Size of the Defect
1. Large : (nonrestrictive) >10mm
– Diameter of the defect equal to diameter of the aortic orifice;
– R...
Atrial Septal
Defect
• An atrial septal defect (ASD) is anAn atrial septal defect (ASD) is an
opening in the atrial septum...
Atrial Septal Defects
1. Ostium Secundum: [most common CHD in adults]
Defect involves tissue of the septum primum at or
ar...
Classification of ASD
Classification of ASDs
• Mild :
Pulm. Art. / Aortic flow ratio < 2:1
(QP – QS Ratio)
• Mod. to Large :
Pulm. Art. / Aortic...
Classification of ASDs
• Small : ASD area < 1 cm2
(Asymptomatic)
• Moderate : ASD area 1 - 3 cm2
(Asymptomatic or mild sym...
Hemodynamics
• Magnitude of L -> R shunt depends
upon
- Size of the defect
- Relative compliance of the ventricles
- Relat...
 RV Conduction delay (rSR’ pattern)
Sino-septal defects
• Involve the area of the atrial septum derived from the
sinus venosus.
• Most commonly this includes ...
AVSD
• Atrioventricular septal defects (AVSD) result
from abnormal development of the membranous
and muscular atrioventric...
ASDs – Echocardiogram
• Secundum atrial defects are well defined on echo from
subcostal view and the defect can be sized.
...
Course & Prognosis
• Most common CHD in adults (OS Type)
• Patients can pass through 3rd
or 4th
decade
with little hardshi...
Course & Prognosis
• Older patients – deteriorate rapidly
• Degeneration of coronary artery, systemic
hypertension leading...
Patent Ductus Arteriosus
Types:Types:
1. Large PDA : significant LV overload, CHF, severe
PAH, murmur unlikely to be loud ...
PDA - Anatomy
PDA
Diagnostic criteria
• Lumen of the
vessel visualized
along the entire
length.
• LAE
• LV dilatation
PDA - Hemodynamics
PDA - Echo
Note: The
Shunt
going from
below
upwards in
the
pulmonary
artery
Natural History of PDA
• Unlike PDA of prematures spontaneous
closure of PDA does not occur. PDA of
term are due to struct...
Timing of Closure
• Large/moderate PDA with CHF, PAH – Early
closure by 3-6 mo. (Class I)
• Moderate PDA, no CHF, PAH : 6 ...
Coarctation of Aorta (COA)
• 8- 10 % of all CHD.
• M:F = 2:1. 30% of Turners Syndrome.
• 85% of COA have bicuspid valve.
•...
Coarctation of the aorta
Diagnostic finding
Aortic lumen is narrowed,
typically distal to the left
subclavian artery.
Hypo...
Coarctation of the aorta -
Hemodynamics
Coarctation of the aorta -
Types
Natural History of COA
• Bicuspid valve may cause stenosis or
regurgitation with age.
• SBE may occur on either aortic val...
Coractation of Aorta
• Diagnosis :
– Absent femoral pulses
– BP in upper and lower limbs
– X- Ray chest
– Echo
– CT angiog...
Coractation of Aorta
• Timing of Intervention :
– With LVH / CHF or severe upper limb hypertension :
Immediate interventio...
Coractation of Aorta
• Mode of Intervention :
– Balloon dilatation of surgery for children> 6 mo. Age
– Surgical repair fo...
Tetrology of Fallot
Infective Endocarditis Prophylaxis
• Every child with CHD must be advised to maintain
good oral hygiene and regular dental...
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
Congenital Heart Diseases
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Congenital Heart Diseases

  1. 1. Congenital Heart DiseasesCongenital Heart Diseases CSN VittalCSN Vittal
  2. 2. Questions we face 1. Does the child have a heart disease? 2. Is it congenital heart disease? 3. What type of lesion? 4. What is the severity of the lesion?
  3. 3. CHD • DEFINITION – PRESENT AT BIRTH • INCIDENCE – 6-8 PER 1000 LIVE BIRTHS IN WESTERN COUNTRIES • ETIOLOGY – IN MAJORITY NOT KNOWN – EQUAL IN BOTH SEXES
  4. 4. APPROACH TO CHD • DOES THE PATIENT REALLY HAVE CHD • IS THE PATIENT CYANOTIC OR ACYANOTIC • IS PULM ARTERIAL BLOO FLOW INC OR NOT • LEFT OR RIGHT SIDE • DOMINANT VENTRICLE • PULM HTN PRESENT OR NOT
  5. 5. • HISTORY – PRENATAL - DM,DRUG ABUSE,SLE – INFANT - FEEDING DIFFICULTIES • SYMPTOMS OF CHF – POOR WEIGHT GAIN,DIFFICULTY IN FEEDING – BREATHS TOO FAST & BREATHS BETTER – WHEN HELD AGAIST THE SHOULDER – PERSISTENT COUGH & WHEEZING – IRRITABILITY, – EXCESSIVE PERSPIRATION & RESTLESSNESS – PUFFINESS OF FACE & PEDAL EDEMA.
  6. 6. Approach to CHD • Does the child have Heart Disease? NADAS Criteria MAJOR 1. Systolic murmur Gr. III or > intensity 2. Diastolic murmur 3. Cyanosis 4. CHF MINOR 1. Systolic murmur Gr. II intensity 2. Abnormal 2nd Sound 3. Abnormal ECG 4. Abnormal Chest X Ray 5. Abnormal Blood Pressure •Presence of 1 major or 2 minor criteria suggestPresence of 1 major or 2 minor criteria suggest presence of Heart Diseasepresence of Heart Disease
  7. 7. Approach to CHD • IS the Heart Disease Congenital? CONGENITAL 1. Recognition early in age 2. Murmurs more parasternally 3. Presence of central cyanosis 4. Presence of extra-cardiac anomalies ACQUIRED 1. H/o. joint pains, fever 2. Apical murmurs
  8. 8. Approach to Heart disease Cyanotic CHDAcyanotic CHD Patient Apply NADAS’ Criteria Heart Disease Present Heart Disease Absent Re-evaluate after Six months L  R Shunts Obstructive Lesions Regurgitant lesions
  9. 9. CHDs Shunting Stenotic R - > L L - > R Mixing Aortic Stenosis Tetrology of Fallot Patent ducturs Truncus Pulmonic Stenosis Transposition VSD TAPVR Coarctation Tricuspid atresia ASD HLH
  10. 10. Approach to CHD • Is it Acyanotic or Cyanotic CYANOTIC 1. Clinical cyanosis – Uniform or Differential 2. R/o. respiratory, CNS or metabolic causes 3. Presence of polycythemia 4. Fast regression of Thymus on X-Ray
  11. 11. Approach to CHD • Pulmonary Blood Flow Is it Normal / Increased / Decreased INCREASED 1. Rec. respiratory infections 2. Cyanosis Mild in Cyanotic CHDs 3. Chest X- Ray • Main pulmonary artery segment increased in size • Rt. And Lt. PA branches larger • Plethoric lung fields
  12. 12. Second Heart Sound S2 S2 A2 P2 Accentuated Diminished Delayed Early SH, AR Calc.AV, Aortic Atresia AS, PDA, AR, LVF, LBBB VSD, MR PAH PS, PA PS, ASD, TAPVC, RBBB
  13. 13. Spliting of Second Heart Sound Expiration InspirationSpliting Normal Wide & Variable Paradoxical Wide & Fixed Single Second Sound MR, VSD, PS ASD, TAPVC, RBBB AS, PDA, AR TOF
  14. 14. Chief complaints • Breathlessness • Palpitation • Chest pain • Cough • Edema • Failure to thrive • Joint pain / swelling • Syncope
  15. 15. History • Gestational and natal history – Infections, (Rubella in 1st trimester, Mumps, CMV, HSV, Coxsackie virus B) – Maternal Conditions • Diabetes, advanced age, SLE, alcoholism, cigarette smoking, etc. – Medications • Amphetamines, Phynetoin, trimethadone, Progesterone – estrogen – Birth weight • IUGR, LGA
  16. 16. History • Postnatal history – Weight gain • Feeding pattern – Prolonged feeding time with multiple interruptions – Dyspnoea during feeding – Poor feeding • Exercise Tolerance – Fatigue while climbing, running, bicycle riding • Cyanosis – Onset, nature, spells • Chest Pain – Deep, heavy pressure, feeling of chocking, triggered by exercise, not effected by respiration • Palpitation – PAT, MVP • Syncope – Differentiate from epilepsy, breath holding spells, hysterical events
  17. 17. • Frequency of respiratory infections – Rec. LRIs, Rec. wheezing or strider • Joint symptoms – Sore throat and joint symptoms • Neurological symptoms – Stroke – cyanotic CHDs, headache – hypoxia, polycythemia, cerebral abscess – Choreic movements – Syncope – ventricular arrhythmias, long QT, MVP • Medications – Antihistamines, aminophylline • Prior records • Family History – Hypertension, CHDs, Rh. fever History
  18. 18. Physical Examination • General examination • Growth • Respiration • Excessive sweating • Colour – Cyanosis – Pallor – Jaundice • Clubbing • Edema • Extracardiac anomalies
  19. 19. Pulse • Peripheral pusles – Lower limb pulses reduced in coarctation of aorta • Acyanosis with bradycardia – AV canal defects • Acyanosis with tachycardia – VSD • Acyanosis with wide pulse pressure – PDA, VSD with AR, AP window
  20. 20. JVP • Prominent ‘a’ wave : – Pulmonay stenosis • Absent ‘a’ wave: – Pulm. Hypertension due to L->R shunt • V waves – Tricuspid regurgitation
  21. 21. Signs & Symptoms of Infective Endocarditis • H/o CHD or any procedures • Fever • Chills • Chest & abdominal pain • Dyspnea • Night sweats • Weight loss • CNS Manifestations • Elevated temperature • Tachycardia • Embolic Phenomena – Roth spot, osler nodes, petechiae, splinter nail bed hemorrages • Janeway lesions • New or changing murmurs • Splenomegaly • Arthritis • Heart failure • Clubbing • Metastatic infection
  22. 22. Signs & Symptoms of PHT • History of Congenital Heart disease • Breathlessness, fatigue, syncope on exertion • Chest pain • Hemoptysis
  23. 23. Signs & Symptoms of failure • Feeding difficulty • Hepatomegaly • Edema on dependent parts • Failure to thrive • Feeding difficulty • Forehead sweating • Breathlessness
  24. 24. CHDs • Specific lesions
  25. 25. Ventricular Septal Defects
  26. 26. Type of VSD Anatomic location is important with regard to chance of spontaneous closure, surgical approach, risk of conducting system involvement and associated valvular dysfunction 1. Type I [5%] : Subarterial (outlet, subpulmonic, supracristal or infundibular) 2. Type II [75-80%] : Perimembranous (subaortic) 3. Type III [9%] : Inlet (AV canal) 4. Type IV [10%] : Muscular
  27. 27. Supracristal VSDs - Clinical • Associated AI Murmur • Systolic murmur heard over pulmonic area that radiates to the Lt. clavicle (similar to PS)
  28. 28. Perimembranous - Supracristal
  29. 29. Muscular VSDs • Representing 10% of isolated VSDs • Completely surrounded by muscle • May be in the – inlet, – trabecular, or – outlet portion of the interventricular septum. • Can be multiple, and have been described as having a "swiss-cheese" appearance. • Depicted by careful echocardiography, particularly with color doppler imaging
  30. 30. Muscular VSDs - Clinical • High frequency systolic murmur which ends prior to systole
  31. 31. Size of the Defect 1. Large : (nonrestrictive) >10mm – Diameter of the defect equal to diameter of the aortic orifice; – RV systolic pressure is systemic, & – Degree of L-> R shunt depends on pulmonary vascular resistance 1. Moderate (restrictive) 5 - 10mm • Diameter of the defect < that of aortic orifice • RV pressure is half to 2/3 systemic & • L-R shunt is > 2:1 1. Small (restrictive) < 5 mm • Diameter of the defect < 1/3 the size of aortic orifice • RV pressure is normal & • L-R shunt is < 2:1
  32. 32. Atrial Septal Defect • An atrial septal defect (ASD) is anAn atrial septal defect (ASD) is an opening in the atrial septum allowingopening in the atrial septum allowing blood to shunt between left and rightblood to shunt between left and right atria.atria. • First described by Rokitansky inFirst described by Rokitansky in 18751875 • Clinical features first described byClinical features first described by Bedford, Pepp and Parkinson inBedford, Pepp and Parkinson in 19411941
  33. 33. Atrial Septal Defects 1. Ostium Secundum: [most common CHD in adults] Defect involves tissue of the septum primum at or around the area of the foramen ovale 1. Sinus Venosus (sinoseptal defects): Defects of the embryological origin of the junction of superior and inferior vena cava into the right atrium The latter defects are often associated with partial anomalous pulmonary venous return. 1. Ostium Primum: Defect involves endocardial cushion tissue. 4. Raghib type Absent coronary sinus with Left SVC connection to left atrium. 5. Multiple coalescent defects Types:
  34. 34. Classification of ASD
  35. 35. Classification of ASDs • Mild : Pulm. Art. / Aortic flow ratio < 2:1 (QP – QS Ratio) • Mod. to Large : Pulm. Art. / Aortic flow ratio > 2:1 Depending upon Shunt Ratio :
  36. 36. Classification of ASDs • Small : ASD area < 1 cm2 (Asymptomatic) • Moderate : ASD area 1 - 3 cm2 (Asymptomatic or mild symptoms due to thromboembolism, arrhythmias) • Large : ASD area > 3 cm2 (Symptomatic, RV overload, thromboembolism, arrhythmias) Depending upon Size :
  37. 37. Hemodynamics • Magnitude of L -> R shunt depends upon - Size of the defect - Relative compliance of the ventricles - Relative resistance in both the pulmonary and systemic circulations
  38. 38.  RV Conduction delay (rSR’ pattern)
  39. 39. Sino-septal defects • Involve the area of the atrial septum derived from the sinus venosus. • Most commonly this includes defects that occur at the junction of the superior vena cava and the right atrium, • The right upper pulmonary veins typically enter the left atrium superiorly and just to the left of the atrial septum and sinus venosus region. When a defect of the superior sinus venosus exists, the flow from these veins may be directed toward the right atrium through the sinus venosus defect. • Alternatively, these veins may truly be anomalous in their drainage and enter the right atrium directly. These defects are known as sinus venosus defects.
  40. 40. AVSD • Atrioventricular septal defects (AVSD) result from abnormal development of the membranous and muscular atrioventricular septum. Depending on severity, the defect can be classified as complete or partial. • The ventricular septal defect is located at the 'inlet' portion of the ventricle and the atrial septal defect occurs as an ostium primum type (a deficiency of the septum primum in its inferior and anterior aspect). • AVSD can accompany other complex congenital heart disorders.
  41. 41. ASDs – Echocardiogram • Secundum atrial defects are well defined on echo from subcostal view and the defect can be sized. • With use of color Doppler flow mapping, a qualitative assessment of shunting and its direction can be obtained. • The four-chamber apical view can assess the shunt- volume effects on size and wall thickness of the right ventricle, but is less reliable for accurately measuring the defect. • The parasternal ventricular short axis view may show a flattened interventricular septum during diastole due to right ventricular volume overload. • TEE can be extremely useful in diagnosis and management since it accurately displays the region of the atrial fossa where the secundum defects occur and can determine eligibility for catheter-guided closure.
  42. 42. Course & Prognosis • Most common CHD in adults (OS Type) • Patients can pass through 3rd or 4th decade with little hardship • Life expectancy is shortened • Recurrent respiratory infections due to shunt • Effort intolerance and fatigue common • Infective endocarditis rare – • Lack of jet lesion • Absence of turbulence because of low velocity of flow across defect
  43. 43. Course & Prognosis • Older patients – deteriorate rapidly • Degeneration of coronary artery, systemic hypertension leading to LVF • Atrial arrhythmias : fibrillation, flutter, PAT • Eisenmenger’s syndrome (seldom < 20 yrs) • 5% infants with large ASDs succumb as early as 1st week of life • Some symptomatic patients may improve due to spontaneous closure
  44. 44. Patent Ductus Arteriosus Types:Types: 1. Large PDA : significant LV overload, CHF, severe PAH, murmur unlikely to be loud or continuous 2. Moderate PDA : some Lt heart overload, mild to moderate PAH, no/mild CHF, murmur is continuous 3. Small PDA : minimal or no Lt heart overload, no PAH or CHF, murmur may be continuous or only systolic 4. Silent PDA : No murmur, no PAH. Diagnosed only on echo Doppler
  45. 45. PDA - Anatomy
  46. 46. PDA Diagnostic criteria • Lumen of the vessel visualized along the entire length. • LAE • LV dilatation
  47. 47. PDA - Hemodynamics
  48. 48. PDA - Echo Note: The Shunt going from below upwards in the pulmonary artery
  49. 49. Natural History of PDA • Unlike PDA of prematures spontaneous closure of PDA does not occur. PDA of term are due to structural abnormality of ductal smooth muscle. • PVOD, CHF or recurrent pneumonia. • SBE, more frequent with small PDA.
  50. 50. Timing of Closure • Large/moderate PDA with CHF, PAH – Early closure by 3-6 mo. (Class I) • Moderate PDA, no CHF, PAH : 6 mo.- 1 yr – (Class I). If failure to thrive – closure can be earlier (class II) • Small PDA – At 12 to 18 mo. (class I) • Silent PDA – Closure not recommended (class III)
  51. 51. Coarctation of Aorta (COA) • 8- 10 % of all CHD. • M:F = 2:1. 30% of Turners Syndrome. • 85% of COA have bicuspid valve. • Poor feeding, dyspnea & poor weight gain, & acute circulatory shock in first 6 weeks . • 20-30% of COA develop CHF by 3 months
  52. 52. Coarctation of the aorta Diagnostic finding Aortic lumen is narrowed, typically distal to the left subclavian artery. Hypoplastic aortic arch Post stenotic dilatation of the aorta. Bicuspid aortic valve. Doppler will show the severity of obstruction.
  53. 53. Coarctation of the aorta - Hemodynamics
  54. 54. Coarctation of the aorta - Types
  55. 55. Natural History of COA • Bicuspid valve may cause stenosis or regurgitation with age. • SBE may occur on either aortic valve or on coarctation. • LV failure, rupture of aorta, ICH, hypertensive encephalopathy may develop during childhood.
  56. 56. Coractation of Aorta • Diagnosis : – Absent femoral pulses – BP in upper and lower limbs – X- Ray chest – Echo – CT angiography – MRI
  57. 57. Coractation of Aorta • Timing of Intervention : – With LVH / CHF or severe upper limb hypertension : Immediate intervention (Class I) – Normal LVH, no CHF & mild upper limb hypertension : Intervention beyond 3-6 mo. Age (Class IIa) – No hypertension, no heart failure, normal ventricular function : Intervention at 1-2 yrs of age. (Class IIa) – Intervention is not indicated if Doppler gradient across coarct segment < 20 mm Hg with normal LV function. (Class III)
  58. 58. Coractation of Aorta • Mode of Intervention : – Balloon dilatation of surgery for children> 6 mo. Age – Surgical repair for infants < 6 mo. Age – Balloon dilatation with stent development in children > 10 yrs age – Elective endovascular stenting of aorta is contraindicated for children < 10 yrs of age (class III)
  59. 59. Tetrology of Fallot
  60. 60. Infective Endocarditis Prophylaxis • Every child with CHD must be advised to maintain good oral hygiene and regular dental check up • Unrepaired CCHDs are high risk conditions for IE. So prophylaxis is mandatory • ASD (secundum type) and valvular PS are low risk conditions for IE – prophylaxis not recommended • Other acyanotic CHDs including bicuspid aortic valve are moderate risk & prophylaxis is recommended • Repaired CHDs with prosthetic material need prophylaxis for first 6 mo. after procedure • Device placement by transcatheter route also require prophylaxis for the first 6 mo.

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