Subtle Signs of Pediatric Heart Failure

Originally published at Pediatric EM Morsels on November 2, 2013.
Reposted with permission.

For anyone who spends time in the adult ED, signs and symptoms of heart failure become rather conspicuous. The increased work of breathing, the JVD, the significant lower extremity edema are noted prior to even entering the room. Unfortunately, the signs and symptoms of heart failure in pediatric patients are not as prominent and require a vigilant mind.

Heart Failure Basics

  • While heart failure is much less common in children than adults (who love to eat fat-laden fast-food), it is still an important disease as it accounts for 10% of pediatric heart transplants in kids.
  • Best defined as a condition in which the heart is unable to provide adequate tissue perfusion to meet the metabolic demands.
  • Four primary factors determine normal cardiac function:
    1. Preload: Directly affects the Frank-Starling Curve
    2. Afterload
    3. Contractility: Kids do not alter their contractility to the same degree adults do.
    4. Heart Rate: CO = HR x SV
  • Conditions that adversely affect any of these factors can lead to heart failure.

Subtle Heart Failure Signs and Symptoms

Certainly the child that presents in overt CHF and shock will catch our attention immediately!  The tachypnea with increased work of breathing, marked pallor, and cold extremities with thready pulses will cause multiple synapses in your brain to fire simultaneously.  “Access, Monitor, CXR” will be announced as you consider the causes of SHOCK [Sepsis, Hypovolemia, Obstructive (Tamponade, Tension Ptx, PE), Cardiogenic, and “K”ortisol deficiency].

While this is a process that we should all be comfortable with, we should also be attuned to the more subtle manifestations of heart failure in children:

Growth Failure / Malnutrition

  • Much of the metabolic currency of a young child is spent on growth, so heart failure will produce failure to thrive.
  • Inadequate tissue perfusion, increased oxygen consumption from increased work of breathing, in addition to decreased ability to feed because of work of breathing all contribute to patients falling off their respective growth curves.


  • While rales are frequently appreciated in adults with heart failure, they are not in young children, particularly infants.
  • A significant amount of alveolar fluid must be present to cause rales in young children – so if you hear rales, then there is likely severe heart failure.
  • Interstitial fluid develops early on, but will present as tachypnea or wheezing or chronic cough.
    • First time wheezers and kids with persistent cough may benefit from a CXR to look for cardiomegaly!


  • Remember, in order to compensate for the diminished cardiac output, the child will ramp up the HR.
  • Additionally, a dysrrhythmia may lead to heart failure.
  • Have low threshold for checking a screening ECG in kids who remain tachycardic despite antipyretics or other therapies.
    • Look for arryhthmias.
    • Look for signs of chamber enlargement!


  • Think of this as the pediatric version of the lower extremity edema that you see in adults.
    • Peripheral edema is an unusual finding in the young.
    • JVD can be difficult to detect (kids have those short, fat necks), but is often present.
  • Can be associated with abdominal pain, nausea, and/or vomiting.
  • Always check for hepatomegaly!
    • Hepatomegaly can help you become aware of potential heart failure and can also help you determine if the child in SHOCK requires fluid resuscitation.
    • One study showed that 1/4 of children who presented with heart failure initially received bolused IV fluids prior to heart failure being diagnosed and then given diuretics.

Moral of the Morsel

Be vigilant (as is often the moral of the Morsels).  Pediatric heart failure can present subtly. Dyspnea / tachypnea in conjunction with abdominal pain (hepatomegaly) warrants consideration of acute heart failure as much as the kid presenting in overt shock.  Check a screening CXR and ECG.

Acute gastroenteritis and acute bronchiolitis can mimic the symptoms of acute heart failure.  Consider heart failure on your differential when you are getting ready to discharge a child with one of these other diagnoses.


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