HI!

Im Emily
and here to
tell you to
pay
attention...this
is a
really great
talk!!!!!!!!!!
Have you seen
my
brother?hes
sooooa
annoying

Congestive Heart Failure in

Children

Thomas R. Burklow, MD
LTC, MC
Asst C., Pediatric Cardiology

Odenwald mountains

Case Presentation

4 month old presents to ER with cc: cold sx

5 day history of increasing cough; afebrile, no rhinorrhea, no ill
contacts.
PMH: unremarkable. vigorous feeder (25-30oz/d) until the last
couple of days.
FHx: father had a leaky valve but was cleared to join the Marines

Physical Examination
VS: HR 165, RR 60, Nl BPs throughout; RA O2
sat mid 80s, increases to 97% on 1/4 L/ O2
Small for age male, nondysmorphic, mild
cyanosis, moderate increased work of breathing
Left chest prominent
Prominent PMI, RRR, S2 obscured by murmur,
gr III pansystolic SRM over apex to left axilla
Liver edge 4 cm below RCM
1+ pulses throughout

Electrocardiogram

Chest X ray

Neckargemund

Cause of Congestive Heart Failure

Excessive

work load: pressure or volume

Normal workload faced by a damaged
myocardium

Etiologies

Neonate

dysfunction
volume
pressure

Infant

Volume
Dysfunction

Child

Palliated congenital
heart disease
AV valve regurgitation
Acute rheumatic fever
Myocarditis
Endocarditis

Clinical manifestations

Infant

feeding difficulties
failure to thrive
diaphoresis
tachycardia
tachypnea

Child

breathlessness
tachycardia
tachypnea
peripheral edema
cardiomegaly

Treatment
Digitalis

oral: 8-10 mcg/kg/day

I.V.: 80% of oral dose
Because of varying metabolism, appropriate dose
varies by age
Rapid digitalization

May be performed over 12-24 hours, 6-12 hours in dire

situations
Calculate TDD (varies by age); administer 1/2 of TDD, followed
by 1/4, then 1/4 of TDD

Case

kg

example: patient weight is 5.5

Effiel Tower at Dusk

Case example
5.5 kg in a 4 month old
Oral TDD for 1 month-2 years is 30-50 mcg/kg
TDD is 220 mcg

Administer 110 mcg now, then 55 mcg in 12 hours, then 55

mcg in 6 hours
IV dose is 80% of the above amounts

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

Levels are helpful only in cases of suspected toxicity,

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

Nutrition
What

are maintenance calories for a

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

Other medications
Diuretics
Furosemide (Lasix); 0.5-1.0 mg/kg/dose
Chlorothiazide (Diuril); 20-50 mg/kg/day
Spironolactone (Aldactone); 1-2 mg/kg/day
Afterload reduction
Captopril (Capoten); 0.1-0.5 mg/kg/dose t.i.d.
Enalapril (Vasotec); 0.1 mg/kg/day
Beta-blocker
Labetolol

Wasnt my dad great!?!?