Management of Congestive Heart Failure in Infants

Furosemide Therapy

The American College of Cardiology recommends initiating furosemide at 1 mg/kg/dose orally or IV every 12-24 hours, with careful monitoring for response and electrolyte disturbances, for infants with mild CHF secondary to VSD 1, 2
At doses ≤2 mg/kg/day, excess potassium loss generally does not occur and potassium supplementation may not be needed, according to the American College of Cardiology 1
If inadequate diuresis occurs, the dose can be increased by 1 mg/kg increments up to a maximum of 10 mg/kg/day, as suggested by the American College of Cardiology and Praxis Medical Insights 2
The American College of Cardiology recommends using the lower end of dosing (1-2 mg/kg/day total) for infants with mild CHF 1, 2
IV administration of furosemide should be given over 5-30 minutes to minimize ototoxicity risk, as recommended by Praxis Medical Insights 2
Never exceed 6 mg/kg/day for longer than 1 week due to significant ototoxicity risk, according to Praxis Medical Insights 2
The absolute maximum dose is 10 mg/kg/day for severe edema, as recommended by Praxis Medical Insights 2

The American College of Cardiology suggests that digoxin use in infants with VSD remains controversial because contractility is frequently normal, but may be beneficial if ventricular function is reduced 1
Evidence from the American College of Cardiology suggests that digoxin may benefit infants with large VSD who have reduced ventricular function or symptomatic heart failure despite other therapies 1
The combination of digoxin and furosemide provides increased contractility over baseline, according to the American College of Cardiology 1
Consider digoxin if the infant shows persistent symptoms despite furosemide therapy, as recommended by the American College of Cardiology 1

Monitor fluid status and urine output, targeting >1 mL/kg/hour with furosemide, as recommended by Praxis Medical Insights 2
Monitor electrolytes, especially potassium, sodium, and chloride, periodically, according to the American Journal of Respiratory and Critical Care Medicine and Praxis Medical Insights 4, 2
Monitor renal function, blood pressure, and weight, as recommended by Praxis Medical Insights and the American College of Cardiology 2, 3
The American Journal of Respiratory and Critical Care Medicine recommends monitoring for hypercalciuria leading to nephrocalcinosis, hypokalemia, and metabolic alkalosis, as well as transient deafness, when using furosemide 4
Hypovolemia and hypotension are potential side effects of furosemide, according to the American College of Cardiology and Praxis Medical Insights 3, 2

Expect increased urination within 1-2 hours of oral furosemide dose, as recommended by the American Journal of Respiratory and Critical Care Medicine 4
Monitor for decreased wet diapers, which may indicate dehydration, according to Praxis Medical Insights 5
Watch for signs of dehydration, such as decreased skin turgor, sunken fontanelle, and lethargy, as recommended by the American College of Cardiology 3
Report decreased urine output, as this may indicate inadequate dosing or worsening renal function, according to Praxis Medical Insights 2

If furosemide alone is inadequate at 2 mg/kg/day, add spironolactone rather than increasing furosemide dose, as recommended by the American Journal of Respiratory and Critical Care Medicine and the American College of Cardiology 4, 1
Spironolactone decreases potassium excretion and may obviate the need for potassium supplementation, according to the American College of Cardiology 1
Monitor for hyperkalemia when using spironolactone, especially with potassium supplementation, as recommended by the American Journal of Respiratory and Critical Care Medicine 4