HEART FAILURE IN CHILDREN (CCF)

Heart failure occurs when the heart is unable to supply output that is sufficient for the metabolic needs of the tissues in the face of adequate venous return. Any severe cardiac condition, severe pneumonia, or anaemia can lead to heart
failure.

Signs of Cardiac Failure

  • Among infants and young children, cardiac failure manifests as;
    • Feeding difficulties and excessive sweating
    • Rapid weight gain
    • Tachycardia
    • Gallop rhythm
    • Respiratory distress
    • Tender hepatomegaly.
  • Among older children, cardiac failure manifests as;
    • Raised jugular venous pressure
    • Dependent oedema
    • Orthopnoea
    • Fatigue
    • Exercise intolerance
    • Basal crepitations.

Investigations

  • Chest x-ray: May show cardiac enlargement as well as evidence of other cardiac or pulmonary lesions
  • Haemogram
  • Urea and electrolytes
  • Electro-cardiogram (ECG)
  • Echocardiography

Management – General

  • Let the child regulate physical activities when out of hospital.
  • Order bed rest in cardiac position.
  • Give oxygen by nasal prongs or catheter for child in severe failure.
  • Restrict salt intake, control fluid intake and measure urine output.
  • Take daily weight if admitted.

Management – Pharmacological

Infants and young children:

  • Diuretics: Give frusemide: IV 1mg/kg per dose (max 2mg/kg/dose), PO 2– 3mg/kg/day (max 6mg/kg/dose).
  • Digoxin: In all cases give ½ total digitalizing dose (TDD) initially, then ¼ TDD after 8 hours, then ¼ TDD after another 8 hours. Daily maintenance dose, ¼ TDD, given in 1 or 2 divided doses. Total digitalizing doses are:
    • Premature babies: 0.03mg/kg PO
    • Full term newborn: 0.03–0.05mg/kg PO
    • Infants less than 2 years: 0.05–0.06mg/kg PO
    • Children 2–10 years: 0.04–0.05mg/kg PO
  • After load: Captopril (ACE inhibitors) – Begin initially 0.5mg/kg/24 hours 8 hourly, increase by 0.5mg/kg/24 hours every 24–48 hours until dose reaches 3–8mg/kg/24 hours, neonates 0.03–2mg/kg/24 hours. Or use enalapril 0.1mg/
    kg/day with gradual increase as needed (max 0.5mg/kg/day up to 40mg/24 hours
  • Note: Electrolytes should be monitored during therapy with diuretics and digoxin.
  • Treat anaemia and sepsis or pneumonia concurrently.

Older children (over 10 yrs):

  • Diuretics: Frusemide 0.5–2mg/kg/dose (max 6mg/kg/dose) IV or PO OD; use higher doses in patients who were already on it.
  • Digoxin: 0.01–0.015/kg/24 hours. Maximum should not exceed adult dose. Divide dose as for the younger child.
  • After load: Captopril 0.3–0.5mg/kg/dose increase gradually to maximum of 6mg/kg/day in 2 or 3 doses per day. Or enalapril dose as in young children.
  • Potassium supplements: Advise patient to eat fruits, e.g., bananas or oranges.
  • Treat underlying causative factor.
  • Maintenance therapy: All children will need maintenance diuretic, digoxin and ACE inhibitors which are continued on outpatient basis.
  • Refer to specialist:
    • Patients who fail to respond to therapy or deteriorate despite therapy.
    • Children with CHD or heart failure of uncertain origin.
    • For definitive treatment of underlying cause.