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Congestive Heart Failure in Children Thomas R. Burklow, MD LTC, MC Asst C., Pediatric Cardiology

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Case Presentation ª 4 month old presents to ER with cc: “cold sx” ª 5 day history of increasing cough; afebrile, no rhinorrhea, no ill contacts. ª PMH: unremarkable. vigorous feeder (25-30oz/d) until the last couple of days. ª FHx: father had a “leaky valve” but was cleared to join the Marines

Physical Examination ª VS: HR 165, RR 60, Nl BPs throughout; RA O 2 sat mid 80’s, increases to 97% on 1/4 L/ O 2 ª Small for age male, nondysmorphic, mild cyanosis, moderate increased work of breathing ª Left chest prominent ª Prominent PMI, RRR, S 2 obscured by murmur, gr III pansystolic SRM over apex to left axilla ª Liver edge 4 cm below RCM ª 1+ pulses throughout

Electrocardiogram

Chest X ray

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Cause of Congestive Heart Failure ª Excessive work load: pressure or volume ª Normal workload faced by a damaged myocardium

Etiologies ª Neonate ã dysfunction ã volume ã pressure ª Infant ã Volume ã Dysfunction ª Child ã Palliated congenital heart disease ã AV valve regurgitation ã Acute rheumatic fever ã Myocarditis ã Endocarditis

Clinical manifestations ª Infant ã feeding difficulties ã failure to thrive ã diaphoresis ã tachycardia ã tachypnea ª Child ã breathlessness ã tachycardia ã tachypnea ã peripheral edema ã cardiomegaly

Treatment ª Digitalis ã oral: 8-10 mcg/kg/day ã I.V.: 80% of oral dose ã Because of varying metabolism, appropriate dose varies by age ã Rapid digitalization ã May be performed over hours, 6-12 hours in dire situations ã Calculate TDD (varies by age); administer 1/2 of TDD, followed by 1/4, then 1/4 of TDD ª Case example: patient weight is 5.5 kg

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Case example ª 5.5 kg in a 4 month old ª Oral TDD for 1 month-2 years is mcg/kg ã TDD is 220 mcg ã Administer 110 mcg now, then 55 mcg in 12 hours, then 55 mcg in 6 hours ã IV dose is 80% of the above amounts ª Maintenance digoxin is approximately 1/4 of TDD, divided b.i.d., or at 50 mcg/cc, 0.1 cc/kg per dose b.i.d.

Digoxin toxicity ª Levels are helpful only in cases of suspected toxicity, not for management ª GI symptoms are common presenting symptoms: nausea, vomiting, anorexia ª Most common sign of cardiac toxicity is arrhythmia: bradycardia, AV block, PVCs ª Treatment includes holding doses for 1-2 half lives, atropine for sinus bradycardia, and “FAB” fragments in cases of significant toxicity

Nutrition ª What are maintenance calories for a normal infant? ª What is the metabolic state of an infant in congestive heart failure? ª What are the caloric requirements for an infant in congestive heart failure?

Other medications ª Diuretics ã Furosemide (Lasix); mg/kg/dose ã Chlorothiazide (Diuril); mg/kg/day ã Spironolactone (Aldactone); 1-2 mg/kg/day ª Afterload reduction ã Captopril (Capoten); mg/kg/dose t.i.d. ã Enalapril (Vasotec); 0.1 mg/kg/day ª Beta-blocker ã Labetolol

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