Congestive Cardiac Failure in Children

2. Lecture-13
CONGESTIVE CARDIAC FAILURE IN CHILDREN
Prof. Dr. Sunil Natha Mhaske
Dean
Dr. Vithalrao Vikhe Patil Foundation’s Medical College
and Hospital,
Ahmednagar (M.S.) India-414111
Mo- 7588024773
Mail-sunilmhaske1970@gmail.com

3. Definition-
• Clinical syndrome in which the heart is unable to pump
enough blood to the body to meet its needs, to dispose of
venous return adequately or a combination of the two.
• Childs heart does not pump enough blood out to the rest of
the body to meet the body's demand for energy.

6. Causes-
Congenital Heart disease-
 VSD
 PDA
 Endocardial Cushion defect
 Hypoplastic left heart syndrome
 TGA
Acquired Heart Disease-
 Metabolic abnormalities
 Viral Myocarditis
 Acute Rheumatic Carditis
 Rheumatic Valvular heart diseases – MR, AR
 Dilated Cardiomyopathy

7. Miscellaneous-
 Supraventricular Tachycardia
 Complete Heart block
 Severe Anemia
 Acute Hypertension
 Bronchopulmonary dysplasia
 Acute cor pulmonale

9. Time of Onset of CCF in Congenital lesions
Age Lesion
Birth to 72 hrs Pulmonary, mitral and aortic atresias or critical
stenosis
4 days to 1 week Hypoplastic left and right heart syndromes,
transposition and malposition of great arteries with
poor mixing
1 to 4 weeks Transposition and malposition complexes,
endocardial fibroelastosis, coarctation of aorta
1 – 2 months Transposition and malposition complexes,
endocardial cushion defects, VSD, PDA, TAPVC,
ALCAPA
2 to 6 months Transposition and malposition complexes, VSD,
PDA, TAPVC, Aortic stenosis, Coarctation of Aorta

10. Clinical features-
Poor growth very sweaty with feedings
Difficulty breathing Sleep more or have less energy
Faster breathing and heart rate Small and wasted appearance
Difficulty eating liver may also be enlarged
Puffiness of the eyes or feet as the
right heart fails.
Delays in reaching developmental
milestones
Chest pain Dizziness
Palpitations Syncope
• Tachycardia
• Gallop rhythm
• Weak thready pulse

14. Ross scoring system for heart failure in infants

17. Diagnosis
• Physical examination
• Electrocardiogram- sinus tachycardia, LV hypertrophy, ST-T
changes, myocardial infarction patterns, and conduction blocks.
• Chest X-ray
• A graded exercise test
• Echocardiogram
• Cardiac catheterization
• Cardiac MRI
• Biomarkers
- natriuretic peptides (brain natriuretic peptide [BNP]
- amino terminal [NT]-proBNP)

18. • Blood glucose
• Serum electrolytes like calcium, phosphorous
• Screening for sepsis
• Antistreptolysin O and C-reactive protein measurement
• Metabolic and genetic testing
• Endomyocardial biopsy

19. Treatment
• Underlying cause should be identified and treated.
• Large left to right shunts- prompt surgical therapy
• A precipitating causes like intercurrent infections, anemia, electrolyte
imbalances, arrhythmia, rheumatic reactivation, infective endocarditis,
drug interactions, drug toxicity, or drug noncompliance should be
identified and corrected if present.
• Indiscriminate administration of intravenous fluid resuscitation is contra-
indicated and will worsen the condition of children with HF.
• In acute decompensation general measures such as bed rest, propped up
position, humidified oxygen sodium, and if required, volume restriction
are followed routinely.
• Infants with CHF require 120–150 Kcal/kg/day of caloric intake and 2–3
mEq/kg/day of sodium.
• Iron supplementation
• Salt restricted diet

20. Drug therapy
• Drug therapy is aimed at reducing the pulmonary or systemic
congestion by the use of diuretics, increasing contractility by
inotropes, and reducing the disproportionately elevated afterload by
vasodilators and other measures.
• Routinely used drugs in the management of cardiac failure in
children include diuretics, digoxin, angiotensin-converting enzyme
inhibitors (ACEIs), spironolactone, beta-blockers, and inotropes.
• The drugs which are still investigational include natriuretic
peptides, vasopressin antagonists, renin inhibitors, endothelin
antagonists, oral phosphodiesterase inhibitors, anti-inflammatory
molecules, nitric oxide agonists, and neuropeptidase antagonists,
etc.

21. Diuretics
• first line agents to reduce systemic and pulmonary congestion.
• Loop diuretics have been the most widely used.
• Frusemide is given intravenously at a dose of 1–2 mg/kg or 1–2 mg/h
infusion.
• For chronic use 1–4 mg/kg of frusemide or 20–40 mg/kg of
chlorothiazide in divided doses are used.
• Patients who are unresponsive to loop diuretic agents alone might
benefit from the addition of a thiazide agent like metolazone.
• Continuous infusion of diuretics is recommended in cases of acute
decompensated HF.
• Diuretic-induced hypokalemia and hypontremia are rare in children.
• Secondary hyperaldosteronism does occur in children so add
spironolactone 1 mg/kg single dose to conserves potassium.

22. Digoxin
• Digoxin has a very narrow safety window and it should be avoided
in premature babies, those with renal failure and those with acute
myocarditis.
• Electrolyte imbalance like hypokalemia and hypomagnesemia
should be promptly corrected to avoid potentiation of toxicity and
development of arrhythmias.
• Rapid digitalization is generally not required.
• In most circumstances, starting with an oral maintenance dose (8–
10 µg/kg/day) with no loading dose is adequate.
• Dose reduction is required in HF patients on carvedilol and
amiodarone targeting lower serum digoxin concentrations (e.g.,
0.5–0.9 ng/ml).

23. Dose:
• Preterm – 10 – 20mcg/kg P.O
• Term – 20 – 30 mcg/kg P.O
• 1 – 5 years – 30 -40 mcg/kg P.O
• 5 – 10 – 20 – 30 mcg/kg P.O
• Adults – 10 – 15 mcg/kg P.O
• IV is 80% of P.O dose
Contra indication –
• WPW syndrome with AF
• Significant AV nodal block
• Diastolic dysfunction
Relative Contraindication –
• low output states – Valvular
stenosis
• High output states – Chronic
corpulmonale and thyrotoxicosis
• Hypokalemia
• Chronic lung disease
• Myxedema
• Acute hypoxemia
• Renal failure
• Co - therapy with drugs altering
digoxine levels or causing
• AV inhibition
• Severe myocarditis

24. Angiotensin-converting enzyme inhibitors and angiotensin II
receptor blockers
• For the treatment of symptomatic LV dysfunction in children,
ACEIs are routinely used unless contra-indicated.
• In children with cardiac failure, the ACEIs which have been most
studied are captopril and enalapril
• Captopril is preferred in neonates (0.4–1.6 mg/kg/day in 3 divided
doses) and infants (0.5–4 mg/kg/day in three divided doses).
• Enalapril is the first choice for those older than 2 years of age
(0.1–0.5 mg/kg/day in two divided doses).
• Children treated with ACEIs should be watched for deterioration
in renal function and hypotension, cough and angioedema.

25. Aldosterone antagonists
• The literature supporting the role of spironolactone in Paediatrics
HF is however limited. Aldosterone antagonist therapy is
reasonable in children with chronic systolic HF.
• It is contra-indicated in patients with renal dysfunction and
hyperkalemia.
• Spironolactone is used most often in children because experience
with eplerenone in children is limited.
• Usual starting dose of spironolactone is 1 mg/kg/day and the
target maximum dose is 2 mg/kg/day.
• Male gynecomastia can occur with spironolactone requiring
replacement with eplerenone. Monitoring of renal function and
serum potassium is required when coadministered with ACEIs.

26. Beta-blockers
• The benefits of beta-blocking agents in children has not yet
proven conclusive.
• Carvedilol is started at 0.05 mg/kg/dose (twice daily) and
increased to 0.4–0.5 mg/kg/dose (twice daily) by doubling the
dose every 2 weeks.
• Metoprolol (0.1–0.2 mg/kg/dose twice daily and increased to 1
mg/kg/dose twice daily) or bisoprolol may be used as an
alternative to carvedilol.
• Beta-blockers should not be administered in acute decompensated
HF.
• Therapy should be started at a small dose and slowly up-titrated.

27. Inotropes
• Common are the catecholaminergic drugs such as dopamine and dobutamine,
and the phosphodiesterase inhibitors such as milrinone and amrinone.
• Catecholaminergic drugs commonly used are dopamine 5–20 mcg/kg/min
and dobutamine 5–20 mcg/kg/min.
• Epinephrine and norepinephrine are associated with arrhythmias and
increased myocardial oxygen demand.
• Milrinone, a phosphodiesterase inhibitor is an inotrope and vasodilator
prevents low cardiac output syndrome after cardiac surgery in infants and
children.
• The loading dose of milrinone is 25–50 mcg/kg/min and maintenance dose is
0.25–1 mcg/kg/min.
• Milrinone causes peripheral vasodilation and should be used with caution in
hypotensive patients.
• Levosimendan is another inotrope with vasodilatory property by a calcium-
sensitizing effect and opening up of vascular ATP-dependent K+ channels. Its

28. Dopamine-
Dose-
< 2.5mcg/kg/min - Increase blood flow to cerebral coronary renal
and splanchnic vascular bed through DA1 postsynaptic receptor.
2.5-5 mcg/kg/mt - Inotropic effect through b receptor
5-10 mcg/kg/mt - Both a and b effects occur.
>10 mcg/kg/mt- Arterial tone progressively increases.
Indications-
Cardiogenic shock with Hypotension
Complication-
 Tachyarrhytmias
 Extremity gangrene
 Increases Pulmonary vascular resistance particularly in
hypoxemic pulmonary hypertension and may suppress central
respiratory drive

29. Afterload Reduction
• Sodium Nitroprusside- 0.5 – 10 mcg/kg/min but infusion at
maximal rate should never last > 10minutes.
• Nitroglycerine-IV infusion – 1- 10 mcg/kg/min
• iondilators
Indication:
 Increased ventricular filling pressure
 Increased systemic vascular resistance
 Normal blood pressure or hypertension
 Systolic BP
Neonate >50 mmHg
1 mo to 12 mo >60mmHg
1 to 12 yrs > 70 + (Age x 2 )

30. Device therapy
• Pacemaker therapy
• Cardiac resynchronization therapy (CRT)
• Mechanical circulatory support.
• Implantable cardioverter defibrillator (ICD) implantation
• Extracorporeal membrane oxygenation (ECMO)
Cardiac transplantation
Heart transplantation remains the therapy of choice for end-stage HF
in children refractory to surgical and medical therapy.

32. Conclusion
• The causes and clinical presentation of HF are different from
adults.
• The overall outcome with HF is better in children than that in
adults.
• There has been a significant advance in the evidence base for the
management of HF in adults. general principles of management
are similar to those in adults.
• There is a compelling need for larger and higher quality studies
on the treatment of cardiac failure in children to provide a more
robust evidence base.

33. Thanks a lot