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By ULY CLINIC staff

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Congestive heart failure in Children

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A state in which the heart cannot deliver an adequate cardiac output to meet the metabolic needs of the body. Causes include congenital heart diseases, rheumatic heart diseases, rheumatic fever, cardiomyopathies and cardiac arrhythmias. Non cardiac causes are severe anaemia, cor-pulmonale as a result of severe acute or chronic lung diseases like severe pneumonia and bronchial asthma.
 

Diagnostic Criteria


Diagnostic is clinical. A patient may present with the following signs and symptoms:-
 

  • Shortness of breath, interrupted breastfeeding or inability to feed, excessive sweating and failure to thrive

  • Tachycardia, tachypnoea and tender hepatomegally.

  • Older children may have oedema of the feet, face or distended neck veins (raised JVP).

  • Hypotension with weak pulses, cold peripheries and poor capillary refill occur in severe acute heart failure.

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Investigations
 

  • Pulse oximetry (Oxygen saturation) and ABG analysis (hyper/hypocarpnoea,hypoxaemia)

  • FBP

  • Serum electrolytes

  • Serum Creatinine and BUN

  • Also do other investigations related to the possible underlying cause eg.

  • Echocardiogram in case of congenital heart disease.
     

Treatment
 

The main goal is to treat the specific cause.
 

Non pharmacological treatment
 

If the patient has respiratory distress, low cardiac output or poor perfusion; support the airways, breathing and circulation.

 

  • Give oxygen 2-4L/min if the child has central cyanosis, SPO2< 90% or severe respiratory distress (respiratory rate of ≥70/min).

  • Nurse in the child in a semi propped-up position (cardiac position).

  • Insert NGT for feeding

  • Transfuse blood (PRBC) in case of severe anaemia.

  • Give Paracetamol in case of ≥ 38.5°C

  • Monitor PR, BP, RR and temperature 6 hourly. complete bed rest until decompensation ends).Educate and involve parents/guardian in the management (low salt diet,

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Pharmacological Treatment
 

Give
 

Digoxin.

  • Digitalization 12.5μg/kg PO in 8 hourly for 24 hours.

  • If oral route not possible, give IV 10μg/kg 8 hourly each given over 15 minutes for the first 24 hours.

  • Maintenance dose 5μg/kg ( 0.005mg/kg) PO 12 hourly
     

    • Note:

      • Nausea, vomiting, blurring of vision, bradycardia may indicate digoxi toxicity.

 

AND

 

Furosemide PO 2mg/kg once a day.
Spironolactone PO 2mg/kg once a day.
 

 

If no improvement ADD


Captopril PO 1mg/kg 12 hourly OR Enalapril PO 0.2mg/kg 12 hourly.
 

If the patient presents with anxiety, stress or dyspnoea, give Morphine IV/IM/SC or PO 0.2mg/kg 4 hourly
 

 

Note:
 

Refer to the next level facility with adequate expertise and facilities.
 

Congenital Heart Diseases (CHD)


Heart diseases that occur during intra-uterine life and can be diagnosed in utero, at birth or later on.
 

Diagnostic Criteria

 

  • Failure to thrive

  • Interrupted breast feeding

  • Recurrent cough and difficulty in breathing

  • Cyanosis and digital clubbing.

  • With Echocardiographic evidence of congenital heart disease
     

Investigations

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  • Chest X-ray

  • Electrocardiogram (ECG)

  • Echocardiogram
     

Treatment
 

Non pharmacological treatment
 

  • Give Oxygen in case of respiratory distress or hypercynotic attack

  • Ensure adequate dietary and fluid intake
     

Complications
 

Common complications are congestive heart failure and paroxysmal hyper cyanotic or hypoxic spells.

Paroxysmal hypercyanotic spells

Such spells occur in children with congenital cyanotic heart diseases (TOF, tricuspid atresia, pulmonary atresia).

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Diagnostic Criteria

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  • Dyspnoea/tachypnoea

  • Restlessness

  • Syncope

  • Worsening of cyanosis

  • Convulsions, lethargy, unconsciousness or hemiparesis.
     

Treatment

 

  • Non Pharmacological treatment

  • Put patient in knee chest position

  • Give 100% Oxygen 4 litres/min.

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Pharmacological treatment

 

  • Give Morphine IV/IM/SC or PO 0.2mg/kg 4 hourly

  • If no improvement response, give Sodium bicarbonate 4.2%, 2ml/kg IV slowly.

  • NS 20ml/kg or transfuse blood if indicated

  • Propranolol IV 0.1mg/kg IV slowly in severe spells OR PO 1mg/kg 12 hourly (continued until surgery is done).

  • If all the above methods fail; general anaesthesia may be attempted in ICU.
     

Note

 

Refer all patients with congenital heart disease to a facility with adequate expertise and facilities.

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Updated on 16.11.2020

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References

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  1. ​Tanzanian Standard treatment guideline for children 2017 edition page 101-103

  2. WHO. Treatment of children living with HIV. https://www.who.int/hiv/topics/paediatric/en/. September 16.2020

  3. WHO. HIV/AIDS. https://www.who.int/news-room/fact-sheets/detail/hiv-aids. September 16.2020

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