This document discusses heart failure in pediatrics. It defines heart failure as the heart's inability to pump enough blood to meet the body's needs. The main causes in children are congenital heart defects and acquired conditions like cardiomyopathy. Common congenital defects that can lead to heart failure include single ventricle, hypoplastic left heart syndrome, and atrioventricular septal defects. Symptoms depend on the age of onset and include poor feeding, fast breathing, cough, and failure to gain weight. Evaluation involves history, exam, echocardiogram, and blood tests. Treatment consists of diuretics, digoxin, and other inotropes to improve cardiac function, along with addressing any precipitating
2. DEFINITION
HEART FAILURE: It is syndrome in which heart is
unable to provide the output required to meet the
metabolic demands of the body(systolic failure)
and/or inability to receive blood in to the
ventricular cavities at low pressure during diastole
(diastolic failure).
8. WHEN TO SUSPECT CCF
• Poor wt gain
• Difficulty in feeding
• Breathes too fast
• Persistent cough and wheezing
• Excessive perspiration, irritability,
restlessness
• Puffiness of face
• Pedal edema
• Diaphoresis
10. ClinicalHistory
NEONATES & INFANTS
• Poor feeding
• Tachypnoea worsening during feeding
• Cold sweet on forehead
• Poor weight gain
OLDER CHILDREN
• Fatigue
• Exercise intolerance
• Dyspnoea
• Puffy eyes & pedal edema
• Growth failure
11. Physical examination
Initial investigations
Right sided failure:
•Hepatomegaly
•Facial & pedal edema
•Jugular venus
engorgement
Left sided failure:
•Tachypnoea
•Tachycardia
•Cough
•Wheezing & Rales
Either side failure:
•Cardiomegaly
•Gallop rhythm
•Cyanosis
•Low vol.pulse
•Absence of wt.gain
•CXR
•Cardiac enlargement
•Pulmonary edema
•12-lead ECG
•Pulse-oximetry, CBG,
hyperoxia test
•Echocardiography
•CBC, U&E, calcium,
creatinine, and LFT
•Blood tests
•Thyroid function
12. Clinical diagnosis of CHF
E c h o c a r d i o g r a m
Structural diagnosis
(eg myopathic, valvular)
Pathophysiological diagnosis
Systolic dysfunction (LVEF < 40%)
Diastolic dysfunction (LVEF > 40%)
Proceed to
treatment guidelines
13. MODIFIED ROSS CLASSIFICTION.
Class I Asymptomatic
Class II Mild tachypnea or diaphoresis with feeding in infants
Dyspnea on exertion in older children
Class III Marked tachypnea or diaphoresis with feeding in infants
Marked dyspnea on exertion
Prolonged feeding times with growth failure
Class IV Symptoms such as tachypnea, retractions,grunting,
or Diaphoresis at rest
14. NYHA CHF classification for infants
NYHA I - NO SIGN
NYHA II - RR>50 , WITH OR WITHOUT HEPATOMEGALY
NYHA III- ALL ABOVE WITH RIB RETRACTION
NYHA IV- RR>60/min H/R>160/ min,
WITH HEPATOMEGALY,RIB RETRACTION
WITH OR WITHOUT POOR PERFUSION.
15. Treatment of heart failure state
• General measures
• Medical management
• Treatment of precipitating factors
• Treatment of special condition
16. General measures
• Propped –up position
• Oxygen
• Adequate calories
• Salt restriction
• Bed rest
• Daily wt
• Mx respiratory failure
18. Medical management
1.Diuretics
- 1st line of drugs
- ↓ pre-load
- Do not improve
CO
or myocardial
contractility
- Hypokalemia and
hypochloremic
alkalosis
2.Inotropic
agents
-Digoxin
-Dobutamine
-Dopamine
-Amrinone
/milrinone
3.Afterload ↓
agents
Dilators:
Arteriolar-
Veno-
Mixed-
4.B -blockers
19. DIURETICS
Act by ↓venous return ,end diastolic
volume, ↓ pulmonary edema & work of
breathing.
Furosemide is diuretic of choice.
Spironolactone(2-4mg/kg/d) may be
used as add on drug.
Metolazone(0.1-0.2mg/kg) has been
tried in frusemide resistant edema.
20. Mechanism of action
DIGITALIS : special role in heart failure by ↑
contractility at the same time depressing SA
node & AV node.
•Its half-life of 36hrs, so given
once or twice daily.
•Its absorbed well by GIT,60-
85%.even in
infants,elixir>tablets.
•Initial effect can be seen
within 30min after oral
administration and within
15min after IV.
•Adjust the dose in patients
with renal failure.
21. How to dizitalize the heart ?
1. Baseline ECG & Serum electrolytes
2. Calculate the oral digoxin dosage :
Age Total dizitalizing
dose(μg/kg)
Maintenance
dose(μg/kg/D)
Prematures 20 5
Newborns 30 8
< 2yrs 40-50 10-12
> 2yrs 30-40 8-10
Maintenance dose is 25% of the total dig.dose in 2 divided doses
I.V. dose is 75% of the oral dose.
3. Give one half of the TDD immediately ,then 1/4th & then the final 1/4th
at 6- to 8-hr intervals.
4. Start the maintenance dose 12hrs after the final TDD but before this do
ECG
22. Other ionotropes:
Phosphodiesterase
inhibitors:
Milrinone/amrinone
• Low cardiac output
refractory
to standard therapy
• After open heart surgery
• Adjunct to DA / Dobutamine
• S/E-thrombocytopenia
Adrenergic agents:
Dopamine
• Inotropic,peripheral
vesodilatation,
increased renal blood flow-
natriuresis
• 5-10mcg/kg/min
• In higher doses- peripheral
vesoconstriction
Dobutamine
•2.5-40mcg/kg/min
•Dose is gradually increased
23. Afterload ↓ agents
• Long term trials with Captopril(0.5-6mg/kg) &
Isosorbide dinitrate(0.1mg/kgq6hr) shown
improvement in symptoms & exercise
capacity.
• Used as add on with diuretics & digoxin.
24. ß BLOCKERS
Effacious in CHF in children due to CHD,
Anthracycline induced cardiomyopathy ,
dilated cardiomyopathy.
Improved left ventricular function & exercise
tolerance, decreased need for heart transplant.
It has been shown to improve clinical symptoms
& neurohormonal markers in infants with CHF
due to Lt to Rt shunts.
Dose should titrated upwards
Avoid in decompensated heart failure.
Carvedilol(initial dose0.08→0.46mg/kg)