Heart disease in children...B.Sc. Nursing & GNM syllabus

Heart disease in children
RahulDhaker
Asst. Professor,
Pal College of Nursing & Medical Sciences,Kathgodam,
Uttarakhand
1

Introduction
• The most common heart disease in children
are congenital heart disease and rheumatic
fever with its consequences.
• Congestive cardiac failure is a common
pediatric emergency, with its different
etiology than that of adults.
2R Dh@ker, Lecturer, PCNMS

• Congenital heart defects are problems with
the heart's structure that are present at birth.
These defects can involve:-
• The interior walls of the heart
• The valves inside the heart
• The arteries and veins that carry blood to
the heart or the body
R Dh@ker, Lecturer, PCNMS 3

• There are many types of congenital heart
defects. They range from simple defects with
no symptoms to complex defects with severe,
life-threatening symptoms.
• They affect 8 out of every 1,000 newborns

Cont…introduction
• Other heart disease which may found in
infants and children are cardiomyopathy,
myocarditis, pericardial disease etc.

Cont…
• Common clinical features of cardiac disease
include-
–Chest pain
–Tachycardia
–Bradycardia
–Dyspnea
–Cyanosis

Cont…
• Sweating during feeding
• Orthropnea
• Feeding difficult
• Clubbing
• Edema
• Chest deformity
• Engorgement of neck veins
• Hepatomegaly etc.

Cont….
• History of illness ,
• Clinical examination, cardiac examination and
auscultation are very important aspect of
diagnostic evaluation before the planning of
investigations.
• The investigations to detect the cardiac problems
and to confirm the diagnosis include -

Cont…
• X-ray studies
• ECG
• Echocardiography
• MRI
• Radionuclide angiography
• Cardiac catheterization
• ABG analysis
• Complete hemogram
• Urinalysis etc.

Fetal
circulation

Congenital Heart disease
• CHD is the structural malformation of the heart
or grater vessels, present at birth.
• It is the most common congenital malformation
• The exact number of prevalence is not known

Etiology
• The exact cause of CHD is unknown in about 90%
of case.
• Heredity and consanguineous marriage are
important etiology factors.
• Genetic disorder and chromosomal aberrations (
trisomy – 21, Turner's syndrome) are also known
to predispose congenital heart disease.

Cont…
• Other associated factors responsible for CHD
include fetal and maternal infections, drug intake,
alcohol intake by mother, maternal IDDM, fetal
hypoxia, birth asphyxia etc.

Classification of CHD
• CHD can be grouped into three categories-
• Acynotic CHD- there is increased pulmonary
blood flow due to left to right shunt. It includes:-
– Ventricular septal defect (VSD)
– Atrial septal defect (ASD)
– Patent ductus arteriosus (PDA)
– Atrio- Ventricular canal (AVC)

Cont…Classification of CHD
• Cyanotic CHD- there is diminished pulmonary
blood flow due to Right to Left shunt. It
includes:-
– Tetralogy of fallot (TOF)
– Tricuspid Atresia (TA)
– Transposition of grater arteries (TGA)
– Hypoplastic left heart syndrome

Cont…
• Obstructive lesions:-
–Coarctation of aorta
–Aortic Value stenosis
–Pulmonary value stenosis
–Congenital mitral stenosis

Ventricular septal Defect (VSD)

• A ventricular septal defect is an opening in the
ventricular septum, or dividing wall between the
two lower chambers of the heart known as the
right and left ventricles.
• VSD is a congenital (present at birth) heart defect.
• As the fetus is growing, something occurs to affect
heart development during the first 8 weeks of
pregnancy, resulting in a VSD

• It is most common acyanotic congenital
heart disease.
• It is found approximately 25% of all CHD.
• The size of defect can be small & large.

Etiology
• In most children, the cause isn't known
• In some cases, the tendency to develop a VSD may
have a genetic basis.
• Risk factors
– Ventricular septal defect appears to run in families
and sometimes occurs with other genetic problems,
such as Down syndrome

Cont….etiology
• Having the following conditions during pregnancy
can increase risk of having a baby with a heart
defect.
– Rubella infection
– Poorly controlled diabetes
– Drug or alcohol use or exposure to certain
substances

Types of VSD
• Membranous VSD
• Muscular VSD
• Atrioventricular canal type VSD
• Conal septal VSD

Symptoms of VSD
• The size of the ventricular septal opening will
affect the type of symptoms noted, the severity of
symptoms, and the age at which they first occur.
• The following are the most common symptoms of
VSD.
– fatigue
– sweating
– rapid breathing
– heavy breathing

Cont…Symptoms of VSD
–congested breathing
–disinterest in feeding, or tiring while feeding
–poor weight gain

Diagnosis
• complete exam and look for signs of VSD, which
may include heart murmurs.
• Tests may perform include:
• chest x-ray
• electrocardiogram (ECG)
• echocardiogram (echo)
• cardiac catheterization
• cardiac magnetic resonance
imaging (MRI)

Treatment for ventricular septal
Defect
31
Specific treatment for VSD will be determined by child's
physician based on:
•Child's age, overall health, and medical history extent of
the disease
•Child's tolerance for specific medications, procedures, or
therapies
•Expectations for the course of the disease
•Opinion or preference
R Dh@ker, Lecturer, PCNMS

Cont…
• Medical management
• adequate nutrition
• infection control
• surgical repair
• interventional cardiac catheterization
• Postoperative care

Medical management
• In small VSD usually no medical management is
required.
• Surgical repairer may be indicated in some cases.
• Prevention of complication is very essential
measure.
• Spontaneous closure of VSD occurs in 30 to 50%
cases with small defect.

Cont…
• In large VSD, initial management of associated
problem like CCF and endocarditis, should be
done with appropriate treatment.
• Surgical is done as one- stage or two-stage
operational.
• One stage operational with patch closure of VSD
by Open-heart method can be performed.

Cont…
• Two stage approach is done with first stage, to
band the pulmonary artery to restrict pulmonary
blood flow by closed- heart methods.
• Second stage operation is done to patch close the
VSD and remove the PA band.

Complication
• The common complication of VSD are CCF,
recurrent respiratory tract infection, infective
endocarditis, pulmonary stenosis, pulmonary
hypertension.

Patent Ducts
Arteriosus

Patent Ducts Arteriosus
• It is persistent vascular connection between the
pulmonary artery and the aorta.
• Functionally the closure of ductus arteriosus occurs
soon after birth.
• When ductus arteriosus remains patent and open after
birth, the blood flow in the ductus from the aorta to
the pulmonary artery due to higher pressure in the
aorta.

• PDA is common in preterm infants who weight
less than 1.5kg.
• It is the more common type in female baby and
occurs approximately 11% of all CHDs.
• A small PDA may cause no symptoms, but a large
one may cause poor eating, failure to thrive or
breathlessness.

• During the first 60 hours of life, spontaneous
closure of the ductus occurs in 55% of full-term
newborn infants.
• By 2-6 months of age, closure occurs in more
than 95% of healthy infants.

Type

Clinical manifestations
• Clinical presentation of PDA depend upon the size
of ductus and its patency.
• Symptomatic cases manifested with –
– Tachycardia
– Bounding pulse
– Dyspnea and frequency respiratory infection.
– Precordial pain,
– hoarseness voice
– Feeding difficulties
– Slow weight gain
– Growth failure 44R Dh@ker, Lecturer, PCNMS

Diagnosis evaluation
• History of illness
• Physical examination
• Chest X-ray
• ECG
• Two- dimensional echocardiogram
• Doppler study

Management
• Medical Management
• Surgical Management

Medical Management
• In symptomatic patient with PDA,
– Indomethanic 0.1 to 0.25mg/kg/IV over 30 minutes
very slowly is administered every 12 to 24 hrs for 3
doses.
– Anti-prostaglandin agent
– Aspirin
• Supportive care is provided with rest, adequate
intake of calorie for weight gain and promotion of
growth and development.

Surgical management
• Transaction or ligation of patent ductus arteriosus
is performed via lateral thoracotomy, a closed
heart intervention.
• It is done preferably between 3 and 10 years of age
in asymptomatic patients and in symptomatic
patients.
• The result of surgery is excellent.
• pre- operative and postoperative care for
thoracic surgery to be provided with all
precaution.

Complication
• CCF
• Infective endocarditis
• Pulmonary hypertension
• Rarely
– Thromboembolism
– Rheumatic heart disease

Atrial Septal
Defect

Introduction
• A "hole" in the wall that separates the top two
chambers of the heart.
• This defect allows oxygen-rich blood to leak into
the oxygen-poor blood chambers in the heart.
• ASD is a defect in the septum between the heart's
two upper chambers (atria). The septum is a wall
that separates the heart's left and right sides.

• Atrial Septal defects occur in 6 percent to 8
percent of all children born with congenital heart
disease.
• For unknown reasons, girls have Atrial Septal
defects twice as often as boys.

Etiology
• The causes of heart defects such as atrial septal defect
among most babies are unknown.
• Some babies have heart defects because of changes in their
genes or chromosomes.
• Very small defects of (less than 5 millimeters or ¼ inch) are
less likely to cause problems. Smaller defects are often
discovered much later in life than larger ones.

• Risk factors- during pregnancy may increase risk
of having a baby with a heart defect, including:-
– Rubella infection
– Drug, tobacco or alcohol use, or exposure to certain
substances
– Diabetes
– Obesity
– Phenylketonuria (PKU)

Epidemiology
• The 3 major types of atrial septal defect (ASD)
account for 10% of all congenital heart disease
and as much as 20-40% of congenital heart
disease presenting in adulthood.
• The most common types of ASD include the
following:-

Cont… Epidemiology
– Ostium secundum: The most common type of ASD
accounting for 75% of all ASD cases, representing
approximately 7% of all congenital cardiac defects and 30-
40% of all congenital heart disease in patients older than 40
years.
– Ostium primum: The second most common type of ASD
accounts for 15-20% of all ASDs.
– Sinus venosus: The least common of the three, sinus
venosus (SV) ASD is seen in 5-10% of all ASDs.

Type
• Ostium secundum atrial septal defect
• Ostium primum atrial septal defect
• Sinus venosus atrial septal defect.
• Coronary sinus atrial septal defect.

Clinical Manifestation
• Many babies born with atrial septal defects don't
have associated signs or symptoms.
• The size of an ASD and its location in the heart
will determine what kinds of symptoms a child
experiences.

Cont… clinical Manifestation
• Shortness of breath, especially when exercising
• Fatigue
• Swelling of legs, feet or abdomen
• Heart palpitations or skipped beats
• Frequent lung infections
• Stroke
• Heart murmur

Diagnostic Evaluation
• physical examination
• Chest X-ray
• Electrocardiogram (ECG)
• Echocardiogram (or “echo”)

Management
• A physician decides the best course of treatment
for ASD based on:
– A child's age, overall health and medical history
– Severity of the disease
– A child's tolerance for specific medications, procedures
or therapies
– Expectations for the course of the disease
– Parents’ opinions or preferences

Medical Management
• Many children have no symptoms and require no
medications.
• Digoxin
• Diuretics

Surgical Management
• A health care provider may recommend surgery
for a child with a large atrial septal defect, even if
there are few symptoms, to prevent problems
later in life.
• Surgery may also be recommended for an adult
who has many or severe symptoms.

• Surgery involves fixing the hole and may be done
through cardiac catheterization or open-heart
surgery.
• Repair of the defect is done by suture closure or
pericardial patch repair by suture closure or
pericardial patch repair by Open Hearth Surgery.

Complication
• Right-sided heart failure
• Heart rhythm abnormalities (arrhythmias)
• Increased risk of a stroke
• Infective endocarditis
• Less common serious
– Pulmonary hypertension

Tetralogy
of
fallot

• Tetralogy of Fallot (TOF) is a congenital heart
defect which is classically understood to involve
four anatomical abnormalities of the heart
• It is the most common cyanotic heart defect, and
the most common cause of blue baby syndrome.
• TOF is usually a right-to-left shunt, in which
higher resistance to right ventricular outflow
results in more severe cyanosis symptoms.

• This condition is characterized by the combinations
of four defect.
– Pulmonary stenosis
– Ventricular defect
– Overriding of aorta
– Right ventricular hypertrophy
• Tetralogy of Fallot is a rare, complex heart defect
that occurs in about 5 out of every 10,000 babies.
• It affects boys and girls equally.

• Ventricular septal defect (VSD)
• Overriding aorta − the aortic valve is enlarged and appears to
arise from both the left and right ventricles instead of the left
ventricle as in normal hearts.
• Pulmonary stenosis − narrowing of the pulmonary valve and
outflow tract or area below the valve that creates an obstruction
(blockage) of blood flow from the right ventricle to the
pulmonary artery.
• Right ventricular hypertrophy − thickening of the muscular
walls of the right ventricle, which occurs because the right
ventricle is pumping at high pressure.

Causes Tetralogy of Fallot
• Cause unknown
• Certain conditions or factors that occur during
pregnancy may raise risk for having a child with
tetralogy of Fallot. These conditions and factors
include:
– German measles (rubella) and some other viral illnesses
– Poor nutrition
– Overuse of alcohol
– Age (being older than 40)
– Diabetes
• Heredity may play a role in causing tetralogy of
Fallot.

Clinical manifestation
• Clinical feature of TOF depend upon size of VSD
and degree of right ventricular outflow
obstruction.
• Blue baby or cyanosis of lips and nailbeds with
Dyspnea is found initially with crying and
exertion in neonates especially when the ductus
arteriosus beings to close.

• Hypercyanotic spells
• Irritability
• Dyspnea
• Cyanosis
• Tet spell
• Flacidity with or without unconsciousness.
• Slow weight gain
• By the age of 2year the child usually develop
clubbing.
• Metabolic acidosis
• Exercise intolerance may develop

Diagnostic test
• Physical examination
• Chest X-ray
• ECG
• Two dimensional ECHO

Management
• The child with TOF should be managed for
cyanosis, hypoxia spells and other associative
complication.
• Oxygen therapy
• Correction of dehydration
• Anemia
• Antibiotic therapy
• Supportive nursing care and continuous
monitoring of child’s condition.

Cont…
• Hypoxic spells should be managed –
– Knee chest position
– Sedative
– Oral propranolol therapy
– IV fluid
– Treatment of acidosis
– Oxygen therapy
• Neonate –
– Prostaglandin E1.

Surgical Management
• Palliative surgery
• Definitive correction
• Complete Intracardiac Repair

Palliative surgery
• Palliative surgery is performed by different
techniques as –
– Modified BT shunt
– Potts operations
– Waterson’s operations

Definitive correction
• It is performed by direct vision open heart
surgery for patch closure of VSD and relief of
right ventricular obstruction.

Complication
• Hypoxia spells
• Polychythemia
• CCF
• Post operative complication including-
– Death
– Arrhythmia
– Exercise disability
– Complete heart block
– Operative complication

Transposition
of
Grater Arteries

• Transposition of the great arteries (TGA) is a heart
condition that is present at birth, and often is called
a congenital heart defect.
• TGA occurs when the two main arteries going out
of the heart—the pulmonary artery and the
aorta—are switched in position, or “transposed”.
• It accounting 5 to 10% of all CHDs.
• It occurs predominantly in males.

•video

Causes
• The cause of TGA is unknown at this time.
• Scientific researchers have found that some
diseases and behaviors might be associated with a
higher risk for TGA. These include:-
– The mother having a viral illness during pregnancy
– The mother having poor nutrition during pregnancy
– The mother using an excessive amount of alcohol
during pregnancy
– The mother being older than 40 years of age
– The mother having diabetes during pregnancy
– The baby having Down syndrome

• Neonate with TGA is presented-
– Severe cyanosis
– Dyspnea
– Metabolic acidosis
– Severe hypoxia
– CCF
• The condition may complicated with-
– Multiorgan ischemia
– Cardiomegaly
– Growth failure
– Clubbing may develop in few months.

• Physical examination- Auscultation of heart sound
• Chest X-ray
• ECG
• ECHO
• angiocardiography

Management
• Medical management of the condition is done with-
– IV prostaglandin E1
– Digoxin
– Diuretics
– Iron therapy
– Severe hypoxia can be treated with balloon atrial
septostomy.

Cont…
• Surgical management is planned depending upon
the associative defect.
• Atrial swith operaton
• Restelli’s operation
• Beffe’s operation

Rastelli operation:

Arterial switch procedure:

Complications:
• Congestive heart failure
• Arrhythmia
• Eisenmenger syndrome (irreversible and
progressive pulmonary vascular obstructive
disease)

Prognosis:
• The overall survival rate following arterial switch
operation is 90%.
• The overall mortality rate following an atrial level
switch is low; however, long-term morbidity
associated with systemic (right) ventricular dilatation
and failure, systemic atrioventricular (tricuspid) valve
regurgitation, and atrial bradyarrhythmias and
tachyarrhythmias is significant.

•Video

Congestive
Cardiac
Failure

• Congestive cardiac failure (CCF) is a common
pediatric emergency.
• It is also termed as congestive heart failure.
• It indicates inadequate cardiac output.
• Heart failure (HF) results from structural or
functional cardiac disorders that impair the ability
of the ventricle(s) to fill with and/or eject blood.

• Heart Failure (HF) is the clinical condition in
which the heart fails to meet the metabolic and
circulatory demands of the body.
• It presents as the final common pathway of a
combination of structural, functional and biologic
mechanisms.
• Pulmonary and/or systemic congestion may
develop as a consequence of heart failure,
resulting in Congestive Heart Failure (CHF)

Definition
• CCF can be defined as “inability of the heart to
maintain an output at rest or during stress,
necessary for the metabolic needs of the body and
inability to receive blood into the ventricular
cavities at low pressure during diastole”.

Causes
• Various forms of congenital heart disease such as
ventricular septal defect (VSD), patent ductus
arteriosus (PDA) or common AV canal
• Heart valve disease caused by Rheumatic fever or
other infections
• Infections of the heart valves and/or heart muscle
(endocarditis)
• Cardiac arrhythmias (irregular heartbeats)
• Cardiomyopathy or another primary disease of the
heart muscle
• Coronary artery disease
• Inflammation of heart muscle (myocarditis)

• Decrease cardiac output leads to inadequate supply of
oxygen and nutrition to the tissue.
• Failure to gain weight in infancy.
• Shortness of breath or labored breathing
• Fatigue
• Needing to take frequent rest breaks while playing
with friends
• Falling asleep when feeding or becoming too tired to
eat during infancy
• Cough and congestion in the lungs
• Sweating 115R Dh@ker, Lecturer, PCNMS

• Weak peripheral pulse
• Cool extremities
• Pallor
• Pulmonary congestion is manifested-
– Tachycardia
– Cyanosis
– Chest retraction
– Nasal flaring
– Grunting
– Cough
– Pulmonary edema

• Detail history of illness
• Physical Examination-
– Palpation of weak peripheral pulse with cold extremities
– Auscultation of heart sound. Rhythm
– Auscultation of lungs
• Chest X-ray
• CBC
• ECG
• ECHO
• Cardiac catheterization (cath)

Management
• Management of CCF is aimed at correction of
inadequate cardiac output.
• This can be achieved by reducing cardiac work,
improving cardiac performance by reducing heart
size and correction the cause of heart failure.

Cont…
• Sedative should be administered to managed
restlessness and to reduce anxiety.
• Diuretics – 0.5-1.5mg/kg.
• Digoxin
• Iron supplement
• Antibiotic
• Vasodilator
• ACE inhibitors

Cont…
• Diet should be planned with low salt for sodium
restriction and to given in small amount
frequently.
• Supportive nursing care should be emphasize-
– Skin care
– Other hygiene measures
– Prevention of infection
– Fluid electrolyte balance
– Diet
– Administration of medication
– Continuous monitoring of child’s condition
– Maintenance of intake output and other record.

Cont…
• Emotional support and health education with
necessary instruction should dietary and activity
restriction, drug intake, prevention of
complication, daily hygiene care and measures of
prevention of infection.

Prognosis
• Prognosis in case of CCF depends upon the cause
and available of treatment.
• Early diagnosis and treatment promote better
prognosis.
• Long term suffering may lead to failure to thrive
and growth retardation.

Acute
Rheumatic Fever

Introduction
• Acute rheumatic fever is an autoimmune
collagen disease occurs as a hypersensitivity
reaction to group-A beta hemolytic
streptococcal infection.
• It is characterized by inflammatory lesion of
connective tissue and endothelial tissue.

• It affect-
– Heart
– Joint
– Blood vessels
– Other connective tissue.
– Brian
• It is the most important acquired heart disease in
children and commonly found in 4 to 15 yr of age
with incidence rate 5.0/1000approximately.
• Rheumatic fever (RF), also known as acute
rheumatic fever (ARF)

Etiology
• Predisposing factors of ARF are-
– genetic predisposition,
– temperate climate,
– winter season,
– unhygienic living condition,
– overcrowding in the family,
– poor dietary intake and
– increasing immunological response.

IN INDIA
• RHD is prevalent in range of 5-7/1000 in 5-15 age
groups.
• About 1 million cases of RHD
• RHD constitutes 20-30% hospital admissions due to
CVD.
• Streptococcal infections common in children living in
under –privileged conditions and RF accounts for 1-
3% of the cases.

• Important cause of chronic disease and death in
developing world
• Underdiagnosed and undertreated
• Ages 5-15 yrs are most susceptible
• Rare <3 yrs
• Common in 3rd world countries
• Environmental factors-- over crowding, poor
sanitation, poverty, poor housing
• Incidence more during fall ,winter & early spring

AGENT FAC.
HOST FAC.
ENVIRONMENTAL
FAC.

Cont…Etiology
• The etiology of
rheumatic fever is
not clear, but there
is strong associative
with beta hemolytic
streptococcal
–Sore throat

Clinical manifestation
• The clinical feature of acute
rheumatic fever can be
grouped as major, minor and
essential manifestations.
• STREPTOCOCCUS SORE
THROAT

A culture positive case of streptococcal pharyngitis with
typical tonsillar in a 16-year-old.
R Dh@ker, Lecturer, PCNMS
134

Cont…
• Major Manifestation-
– Carditis
– Polyarthritis
– Chorea
• it is purposeless involuntary, rapid movement.
Usually associated with muscle weakness,
speech disturbance
– Subcutaneous nodules-
• It is found as firm painless nodule over the
extensor surface of certain joints( elbows, knees
and wrists).

Erythema
marginatum
Subcutaneous
nodules

Closer view of erythema marginatum
Erythema marginatum on the trunk,
showing erythematous lesions with
pale centers and rounded or
serpiginous margins

Cont…
• Minor manifestation-
– Fever
– ECG changes with prolonged P-R interval
– Elevate ESR
• Essential Criteria
– Elevated ASO titer – indicate streptococcal
infection(normal 200 IU/ml)
– Positive throat swab culture- streptococcal infection

• Other manifestation-
– Pericardial pain
– Abdominal pain
– Headache
– General weakness
– Tachycardia
– Sweating
– Vomiting
– skin rash
– Anemia
– Pleuritis
– Weight loss
Cont…

• Doppler ECHO
• Endomycocardial biopsy
• Chest X-ray
• ECG
• Blood test
– ESR
– ASO- titer
– WBC count

Management
• Bed rest
• Nutritious diet
– Provide of protein, vitamins,
– Salt restriction is not necessary unless CCF is present.
– Avoid rich spicy food

Cont… Management
• Antibiotic therapy- penicillin is administered after skin test
to eradicate streptococcal infection.
• Penicillin 4 lacks unite deep IM, twice a day is given for 10
to 14 days.
• Benzathine penicillin 1.2 mega units every 21 days or 0.6
mega units every 15 days to given.
• Oral penicillin 4 lacks units (250mg), every 4 to 6 hours for
10 to 14 days.
• Erythomycin can be used in penicillin sensitive patients.

• Aspirin is administered as suppressive therapy to
control pain and inflammation of joint
• Dose of Aspirin 90 to 120 mg/kg/day in 4 divided.
• It may be needed for 12 weeks
• Steroid( prednisolone) therapy is given as
suppressive therapy along with aspirin.
• the initial dose is 40 to 60 mg/day or 2 mg/kg/day in
divided 4 dose, 7 to 10 days.
Cont… Management

• Management of chorea can be done with diazepam
or phenobarbitone.
• Treatment of complication if present, symptomatic
care to be provided accordingly.
Cont… Management

Heart disease in children...B.Sc. Nursing & GNM syllabus

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Heart disease in children...B.Sc. Nursing & GNM syllabus