Dr. Eke Eghosasere Paul gave a presentation on pediatric heart failure to the Nelson Club on September 15, 2014. The presentation covered the epidemiology, etiology, pathophysiology, clinical signs and symptoms, diagnosis, treatment and prognosis of heart failure in children. Heart failure occurs when the heart cannot meet the body's metabolic needs due to reduced cardiac output. Compensatory mechanisms initially help maintain function but eventually become ineffective, leading to worsening clinical symptoms. Proper diagnosis and management of the underlying cause are important for treatment.

1. Nelson Club Presentation
By
Dr. Eke Eghosasere Paul
15th September, 2014

2. Outline
 Introduction
 Epidemiology
 Aetiology
 Pathophysiology
 Clinical Features: Signs and Symptoms
 Diagnosis
 Treatment
 Prognosis
 Conclusion
 References
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3. Introduction
DEFINITION OF TERMS
 Cardiac Output: the amount of blood the heart pumps
through the circulatory system in a minute
 Stroke Volume: the amount of blood put out by the left
ventricle in one contraction
Cardiac Ouput = Stroke Volume X Heart Rate
 Preload: the magnitude of the maximal (end-diastolic)
ventricular volume or the end-diastolic pressure
stretching the ventricles
 Afterload: the resistance against which the left
ventricle must eject its volume of blood during
contraction 3

4. Introduction Contd.
 Heart failure occurs when the heart cannot deliver
adequate cardiac output to meet the metabolic needs
of the body
 In the early stages of heart failure, various
compensatory mechanisms are evoked to maintain
normal metabolic function
 When these mechanisms become ineffective,
increasingly severe clinical manifestations result
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5. Epidemiology
 Accurately estimating the incidence in children is
problematic
 In USA, incidence of heart failure due to congenital
defects is between 1-2 per 1000 live births
 Cardiomyopathy contributes significantly to pediatric
cases that present with heart failure (0.87 per 100,000
in the UK)
 Data from Nigeria suggests that 7.02% of emergency
paediatric admissions to a tertiary hospital are for
cardiac failure
 Over 90% of those cases are from lower socio-
economic groups
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6. FETAL
 Severe anemia (hemolysis, fetal-maternal transfusion,
parvovirus B19-induced anemia, hypoplastic anemia)
 Supraventricular tachycardia
 Ventricular tachycardia
 Complete heart block
PREMATURE NEONATE
 Fluid overload
 Patent ductus arteriosus
 Ventricular septal defect
 Cor pulmonale (bronchopulmonary dysplasia)
 Hypertension
FULL-TERM NEONATE
 Asphyxial cardiomyopathy
 Arteriovenous malformation (vein of Galen, hepatic)
 Left-sided obstructive lesions (coarctation of aorta,
hypoplastic left heart syndrome)
 Large mixing cardiac defects (single ventricle, truncus
arteriosus)
 Viral myocarditis
INFANT-TODDLER
 Left-to-right cardiac shunts (ventricular septal defect)
 Hemangioma (arteriovenous malformation)
 Anomalous left coronary artery
 Metabolic cardiomyopathy
 Acute hypertension (hemolytic-uremic syndrome)
 Supraventricular tachycardia
 Kawasaki disease
 Viral myocarditis
CHILD-ADOLESCENT
 Rheumatic fever
 Acute hypertension (glomerulonephritis)
 Viral myocarditis
 Thyrotoxicosis
 Hemochromatosis-hemosiderosis
 Cancer therapy (radiation, doxorubicin)
 Sickle cell anemia
 Endocarditis
 Cor pulmonale (cystic fibrosis)
 Cardiomyopathy (hypertrophic, dilated)
AETIOLOGY
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7. Pathophysiology
 Cardiac output in a normal heart is directly
proportional to preload, inversely proportional to
afterload
 ↑Preload → ↑ Cardiac Output, until a maximum is
reached and cardiac output can no longer be
augmented (the Frank-Starling principle)
 Stretching of myocardial fibres → ↑ Stroke Volume
↓
↑ Increased wall tension → ↑myocardial O2 consumption
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8. 8
Left Ventricular End-Diastolic Pressure (mmHg)

9. 9

10. Clinical Features
Right Heart Failure Left Heart Failure
Oedema Dyspnoea (on exertion, at rest,
orthopnoea, PND)
Right hypochondrial pain (enlarging
liver)
Cough (initially dry, later mucoid,
mucopurulent, frothy, blood-stained)
Abdomial distension (liver, ascites)
Anorexia
Fullness after small helpings of food
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Symptoms:
Infants may present with poor feeding/refusal of feeds, FTT, irritability
and weak cry, noisy respirations, interccostal and subcostal recessions,
flaring of ala nasa

11. Right Heart Failure Left Heart Failure
Ankle oedema Dyspnoea
Tender hepatomegaly Basal crepititions + rhonchi
Ascites S3 or S4 gallop rhythm
Raised JVP, pulsatile Pulsus alternans
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Signs:
• Tachycardia
• Tachypnoea with respiratory distress
• Weak peripheral pulses and/or delayed capillary refill
• Muffled heart sounds
• Murmurs of the original disease
• Arrhythmias may be present

12. DIAGNOSIS
A. SPECIFIC
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• Chest X-Ray

13. • Echocardiography
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A. Normal Echocardiograph B. Echocardiograph showing VSD

14. Other Investigations
 Full blood count
 Serum electrolyte, urea and creatinine
 Random blood sugar
 ASO titre, CRP
 B-Type natriuretic peptide
 Urinalysis
 Electrocardiograph
 Doppler
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15. Treatment
APPROACH CONSIDERATIONS:
 Understanding the aetiology
 Reducing the preload
 Enhancing cardiac contractility
 Reducing the afterload
 Improving oxygen delivery
 Enhancing nutrition
MANAGING TEAM:
 Paediatric Cardiologist, Paediatric Surgeon,
Nutritionist, Anaesthetist, Welfare Worker,
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16. Treatment
EMERGENCY MANAGEMENT
 ABC, oxygen inhalation
 Connect to a cardiac monitor
 Secure an IV line
 If in shock, intubate and ventilate
 Keep fluid input/output chart
 Fluid restriction 70% ml/kg/day
 If baby is tachypnoeic, consider NG tube feeding
 Monitor serum electrolytes frequently (especially
potassium)
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17. General Management
 Bed rest, restriction of activities
 Diet: salt and water restriction (older
children), increased caloric intake, NG tube
feeding
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18. Therapeutics
DIGITALIS: Digoxin
 Half the total digitalizing dose is given immediately
and the succeeding two one-quarter doses at 12 hr
intervals later
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Age (Years) Digitalization
(mg/kg/24hr)
Maintenance (mg/kg/24hr)
< 1 month 0.04 — 0.06 0.01
1 month – 2years 0.04 — 0.08 0.01 — 0.02
> 2 years 0.04 — 0.06 0.01
Adult 0.5 — 1.0
(mg/24hrs)
0.25 — 0.5
(mg/24hrs)

19. 19

20. Prognosis
 Depends on the underlying cause, stage of
presentation at the hospital, early/accurate diagnosis,
speed of instituting correct therapy, socioeconomic
factor, availability of specialized treatment centres for
surgeries
 Follow-up
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21. Conclusion
 Heart failure is a common clinical condition in
children which can present at any age
 Cases of heart failure should be thoroughly assessed
and investigated for underlying cause for appropriate
diagnosis/treatment
 Management is usually multifaceted involving several
departments
 Follow up is essential to monitor progress, and ensure
proper development of the child
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22. References
 Nelson Textbook of Paediatrics, 19th Edition; Heart
Failure
 Paediatrics and Child Health in a Tropical Region 2nd
Edition, by Azubuike and Nkanginieme; Heart Failure
in Childhood
 Medscape Article: Paediatric Congestive Heart Failure
 Approach to Paediatric Emergency, by Jaydeep
Choudhury and Jayanta Bandyopadhyay
 A Compendium of Clinical Medicine by A.O. Falase
and O.O. Akinkugbe
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