Subtle Signs of Pediatric Heart Failure

Subtle Signs of Pediatric Heart Failure

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-foot), it is still an important disease as it accounts for 10% of pediatric heart transplants in kids.
  • Best defined as condition in which the heart is unable to provide adequate tissue perfusion to meet the metabolic demands.
  • 4 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.
  • Tachypnea
    • While rales are frequently appreciated in adults with heart failure, they are not in young children, particularly infants.
    • A significant amount of aveolar fluid must be present to cause rales in young children – so if you hear rales, then there is likely severe heart failure.
    • Interstitialfluid develops early on, but will present as tachypnea or wheezing or chronic cough.
      • 1st time wheezers and kids with persistent cough may benefit from a CXR to look for Cardiomegaly!
  • Tachycardia
    • 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!
  • Hepatomegaly
    • 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).  Heart Failure in children 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.

Macicek SM, Macias CG, Jefferies JL, Kim JJ, Price JF. Acute Heart Failure Syndromes in the Pediatric Emergency Department. Pediatrics. 2009 November; 124(1): e898-e904.
Burch M. Heart Failure in the Young. Heart. 2002 August; 88(2): 198-202.


Sean M. Fox
Sean M. Fox
Articles: 583


  1. I say he has suffered severely with bromchilitus and fever as well he has been referred for cardiac issues to st Thomas and a dietician what I find a joke is he is 8 months and I have been battling since he was 6 weeks that’s how much I know my own child

  2. My son has been referred to st Thomas’s for care as he was to SKUBU when he was new born he was premature unfortunately had a lot of issues my question is his heart rate is below 80bp and has an issue breathing and eating at same time he has severe reflux as well as a severe issue with sweating as in bucket loads especially during feeds I have to have a fan on him constantly. I battle and have battled woth go since he was born to explain these issues but responses have been your 1st time mum blah blah blah I am also a sibling of 7 and an aunty to 8 I am no fool and know my child can you please indicate whilst I wait impatiently if I should be as worried as I am for my baby. Thank you

    • Alexandra,
      I am, obviously, not able to give specific medical advice out individuals, but I will say that sweating while feeding is abnormal. In situations like this, often providers and parents are not communicating well with each other. There may have already been an evaluation that reassured them that they haven’t expressed, or they may have not completely heard your concerns.
      I wish you and your family the best,

  3. Thanks for sharing this information about signs of heart failure in children. It’s good to know that there are so many ways to identify heart failure. I can see how malnutrition and failure to grow would be a sign of trouble. If I ever have kids, I’ll definitely keep an eye out for signs like this.

  4. […] a baseline paranoia helping us to remain ever vigilant.  It also helps to have keen eyesight for subtle red flags. Recently we discussed osteosarcoma, but the child with leg pain will much more likely have […]

  5. Great post. Thanks… Makes learning so much easier when in manageable size and appropriate info.. Keep them coming I have lots to learn. Kate

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