Initial Approach to Pediatric Heart Failure

Presentation and Diagnosis

The American College of Cardiology recommends that tachypnea be defined as >50 respirations/minute in children <2 years and >40 respirations/minute in children >2 years, generally without visible respiratory effort 3, 4
Tachycardia sinusal is a common presentation of heart failure in children 4
Hepatomegaly (without splenomegaly) is a sign of heart failure in children 4
Diaphoresis and mottled skin are signs of circulatory decompensation in children with heart failure 4
In infants, difficulties with feeding (>20 minutes to finish a bottle), excessive sweating, and growth retardation are signs of heart failure 2
Heart failure in infants can be confused with septicemia 4

The initial diagnostic evaluation should include examination of pulse volume in all four limbs and carotid arteries 4
Blood pressure measurement in all four limbs to rule out coarctation 4
Laboratory tests, including complete blood count, electrolytes, glucose, calcium, and creatinine, should be performed 5, 6
Chest radiography to rule out pleural effusion, pneumonia, and anatomical anomalies 4
Electrocardiography to rule out rhythm disturbances (chronic tachyarrhythmias can cause cardiomyopathy) 4
Echocardiography is the essential diagnostic examination, which can classify heart failure into five main categories that determine management 2, 5

The American College of Cardiology recommends that the initial management of pediatric heart failure vary according to the underlying etiology identified by echocardiography 2, 5
For congenital heart disease with left-to-right shunt, administer intravenous furosemide and avoid oxygen therapy before anatomical diagnosis 2, 5
For congenital heart disease with systemic outflow obstruction, administer prostaglandin E1 to dilate the arterial duct and avoid oxygen therapy 2, 5
For dilated cardiomyopathy, use diuretics (furosemide), digoxin, and ACE inhibitors, with similar treatment principles as in adults 5
For arrhythmias, treat the underlying arrhythmia, as chronic tachyarrhythmias can cause dilated cardiomyopathy and heart failure 5

The majority of infants with heart failure have a surgically correctable cause 3
Idiopathic dilated cardiomyopathy should be diagnosed by exclusion 5
If echocardiography does not show normal coronary anatomy, cardiac catheterization should be performed 5
Intravenous inotropic agents used in children (dobutamine, dopamine, epinephrine, isoproterenol) are generally similar to those used in adults 2
Vasodilators are generally contraindicated in patients with Eisenmenger syndrome, unless the shunt has been surgically corrected 5