BIG HEARTS, LITTLE BODIES: Pediatric Congestive Heart Failure

by Vanessa Ogueri, MD (’21)
Teaching Resident Capstone Project
reviewed by Kristin Lombardi, MD (Pediatric Cardiology)

When we hear CHF or congestive heart failure, most times our minds tend to drift towards our adult colleagues who help manage the acute and chronic manifestations of heart failure. As pediatricians, luckily, this is a phenomenon we do not often encounter. While infrequent, it is a diagnosis that should be quickly recognized and treated.

Truthfully, the definition of CHF is not completely unified or agreed upon, but simply represents a point when cardiac output cannot meet metabolic demands. According to the International Society for Heart and Lung transplantation “[Heart failure] in children is a clinical and pathophysiologic syndrome that results from ventricular dysfunction, volume, or pressure overload, alone or in combination.” This dysfunction may lead to increased preload, afterload, arrhythmias, and/or impaired contractility. 

CHF leads to multisystem dysfunction due to the downstream effects on cardiac output. The Renin-Angiotensin system and cytokine induced inflammation are activated. With more mineralocorticoid activation in the long-term stroke volume decreases and cardiac hypertrophy ensues. 

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These factors lead to an array of clinical symptoms which are often quite similar to other respiratory and metabolic causes for distress. 

– Feeding difficulties secondary to dyspnea, fatiguability, and secretion of anorexic hormones due to volumes
– Sweating, FTT, retractions, tachypnea, and grunting, tachycardia, gallop, poor perfusion and hepatomegaly

– Exercise intolerance, somnolence
– Cough, wheezing, crackles
– JVD and peripheral edema

In pediatric patients, the most common cause of CHF is Congenital Heart Disease (CHD). There are also a variety of acquired causes for CHF which should always be included on the differential diagnosis when coupled with history, physical examination, laboratory studies and imaging.

– Shunts:
– VSD, PDA, ASD, single ventricle
– Inflow/Outflow obstruction:
– MS, coarctation of aorta, cor triatiatum
– Regurgitant valve
– Inborn Errors of Metabolism

– Kawasaki Disease
– Endocarditis/Myocarditis
– Rheumatic Heart Disease
– Hypertension
– Anemia
– Renal failure

Definitive guidelines on staging are available for adults, but less so defined in pediatric patients due to gaps in quality studies. The New York Heart Association heart failure guidelines are not applicable to children; therefore, the Modified Ross Classification of CHF utilizes symptomatology to classify stage of CHF in pediatric patients less than 6 years old.


Management of CHF is very similar to that of adults and includes the use of a variety of classes of medications. Some of the testing used to help evaluate a patient with suspected CHF may include CXR, ECG, and/or an echocardiogram. Remember, however, that the diagnosis of CHF is largely made clinically (based on history and exam findings).  Diuretic therapy is often needed, and If signs of cardiovascular instability are present ionotropic therapy may be necessary. The primary goals in management include avoiding intravascular depletion while optimizing myocardial oxygen demand and function. Depending on stage of CHF, therapy can be individually titrated.

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Although a patient’s caloric intake may at first seem appropriate, if they are in CHF, they will have increased energy expenditure which will ultimately leave them at a caloric deficit. Some studies have shown caloric intake of 140-200 kcal/kg day were required to cause catch-up growth. Essentially, we tend to increase caloric density not only to increase daily intake but to also decrease total volume intake. This may include the use of nasogastric tube, percutaneous gastrostomy tube or total parenteral nutrition.  

Here at Hasbro our multidisciplinary teams have heart, see hearts, and are well equipped to treat them; we hope you are too!


  • American Academy of Pediatrics. Heart Failure. In: McInerny TK, Adam HM, Campbell DE, DeWitt TG, Foy JM, Kamat DM, eds. American Academy of Pediatrics Textbook of Pediatric Care, 2nd Edition. American Academy of Pediatrics; 2017
  • Leitch CA. Nutritional aspects of pediatric heart failure. In: Shaddy RE, Wernovsky G, eds. Pediatric Heart Failure. Boca Raton, FL: Taylor and Francis; 2005
  • Madriago. Pediatrics in Review Jan 2010, 31 (1) 4-12; DOI: 10.1542/pir.31-1-4¡
  • Price. Pediatrics in Review Feb 2019, 40 (2) 60-70; DOI: 10.1542/pir.2016-0168
  • Rosenthal D, Chrisant MR, Edens E et al. International Society for Heart and Lung Transplantation: Practice guidelines for management of heart failure in children. J Heart Lung Transplant. 2004;23:1313–33