Synopsis
Recognise age-specific heart failure, distinguish congestion from shock, identify congenital, myocardial and rhythm causes, and deliver stabilisation, nutritional support and specialist treatment with safe weight-based prescribing.
- Heart failure is inability of the cardiovascular system to meet metabolic needs without excessive filling pressures; children more often present with feeding, breathing, growth and perfusion problems than ankle oedema.
- In early infancy, major causes include large left-to-right shunts, critical obstruction, cardiomyopathy, myocarditis and sustained SVT; in older children add repaired congenital disease, renal or systemic hypertension and acquired myocardial disease.
- Infant features are tachypnoea, recession, prolonged or interrupted feeds, forehead sweating, poor weight gain and hepatomegaly. Older children report fatigue, reduced exercise, breathlessness, abdominal discomfort, oedema or palpitations.
- Differentiate congestion from low output. Crackles, hepatomegaly and venous or pulmonary fluid indicate congestion; cool limbs, oliguria, altered mentation and lactate indicate inadequate perfusion, and both can coexist.
- Initial assessment includes age-specific observations, four-limb pulses and pressure, saturation, weight trajectory, ECG, chest radiograph, blood count, electrolytes, renal, liver, glucose, gas, lactate and urgent echocardiography when unwell.
- Echocardiography is the key structural and functional test, defining anatomy, ventricular function, valve disease, pressure estimates, shunts and pericardial fluid; a normal ejection fraction does not exclude abnormal filling or circulation-specific failure.
- Acute management is cause and physiology directed: ventilation support, careful preload, diuresis for congestion, rhythm conversion, treatment of infection or myocarditis and urgent repair of critical structural disease.
- Licensed oral Frusol paediatric dosing is 1–3 mg/kg once daily, maximum 40 mg/day, titrated to response by the specialist; formulation strength, renal function, sodium and potassium require checking.
- Nutrition is treatment: use energy-dense feeds, small frequent volumes, nasogastric support and dietetic input when safe oral intake cannot meet growth requirements.
- Chronic disease-modifying medicines in children depend on diagnosis, ventricular physiology, age and evidence and should be initiated and titrated by paediatric heart-failure specialists rather than copied from an adult pathway.
- Escalate refractory failure to a specialist centre for advanced imaging, catheter haemodynamics, genetic or metabolic evaluation, mechanical circulatory support and transplant assessment.
Key red flags
Poor respiratory effort, exhaustion, increasing oxygen requirement, altered responsiveness or rising carbon dioxide indicates impending ventilatory failure.
Hypotension is a late sign in children; cool peripheries, weak pulses, prolonged refill, oliguria and rising lactate reveal low output earlier.
A newborn with shock or weak femoral pulses may have duct-dependent obstruction and needs prostaglandin-pathway assessment rather than routine heart-failure treatment alone.
A sustained tachyarrhythmia can both imitate and cause heart failure; obtain a rhythm strip before assuming all tachycardia is compensatory.
Chest pain, troponin elevation, ventricular arrhythmia or sudden deterioration after viral illness raises myocarditis and requires intensive cardiac monitoring.
Faltering growth, feed duration over roughly 30 minutes, diaphoresis or recurrent admissions represents clinically important chronic burden even when resting saturation is normal.
Investigation priorities
Separate congestion, low output, cyanosis and nutritional burden and detect duct-dependent obstruction.
Management branches
The child has respiratory failure, poor perfusion, acidosis, altered consciousness or hypotension.
- Call intensive-care and cardiology support, monitor continuously and provide airway and ventilation assistance.
- Obtain ECG, gas, lactate and urgent echocardiography while treating hypoglycaemia, sepsis, arrhythmia or duct-dependent disease.
- Use small reassessed fluid, diuretic or vasoactive treatment according to congestion, preload and ventricular physiology rather than a generic shock bolus sequence.