European Journal of Cardiovascular Medicine

Congestive heart failure (CHF) in children is a complex clinical syndrome resulting from the heart’s inability to pump blood effectively to meet the metabolic demands of the body or to do so only at elevated filling pressures. Unlike adults, where ischemic heart disease predominates, pediatric CHF is most commonly caused by congenital heart defects, cardiomyopathies, myocarditis, and, in certain regions, rheumatic heart disease [1,2]. The pathophysiology involves impaired myocardial contractility, volume or pressure overload, and compensatory neurohormonal activation, which initially maintain cardiac output but ultimately contribute to disease progression [2,3].

The clinical manifestations of paediatric CHF are highly variable and largely depend on age, aetiology, and severity of cardiac dysfunction. Infants often present with feeding difficulties, diaphoresis, tachypnoea, and failure to thrive due to increased metabolic demands and pulmonary congestion [2]. Older children may present with exercise intolerance, dyspnoea on exertion, orthopnoea, peripheral edema, and hepatomegaly, reflecting progressive ventricular dysfunction and systemic venous congestion [3]. Physical examination findings such as tachycardia, displaced apical impulse, rales, murmurs, and hepatomegaly are critical for early diagnosis. Classification systems, such as the Ross classification for infants, help stratify severity and guide management [4].

Early recognition of these clinical features is essential, as paediatric CHF is associated with significant morbidity and mortality if left untreated. Understanding the spectrum of clinical presentations aids in timely diagnosis, appropriate intervention, and monitoring of therapeutic outcomes.

Aim

To study the clinical presentation of pediatric patients with congestive heart failure.

Objectives

To describe the demographic profile (age, sex) of children presenting with CHF.

To identify the common etiologies of pediatric CHF in the study population.

To document the spectrum of clinical signs and symptoms of CHF in children.

To classify the severity of CHF using appropriate clinical scoring systems (e.g., Ross classification). To correlate clinical features with underlying etiologies and age groups.

Study Design This was a hospital-based, observational cross-sectional study conducted over a period of 12 months at the Department of Department of paediatrics and Cardiology at Konaseema institute of medical sciences Amalapuram AP India a tertiary care teaching hospital, between January 2021 and December 2021 after obtaining clearance from the Institutional Ethics Committee. Study Population Children aged neonates to 12 years presenting with clinical features suggestive of congestive heart failure (CHF) were included. CHF was diagnosed based on a combination of history, physical examination, and echocardiographic findings [4]. Inclusion Criteria Children aged 0–12 years diagnosed with CHF. Both sexes. Children whose parents or guardians provided written informed consent. Exclusion Criteria Children with isolated arrhythmias without heart failure. Children with severe non-cardiac systemic illness (e.g., chronic renal failure, severe anemia) contributing to cardiac symptoms. Refusal of consent by parents or guardians. Data Collection A structured proforma was used to collect data regarding: Demographic characteristics: age, sex. Clinical history: - feeding difficulties, dyspnea, cough, exercise intolerance, cyanosis, history of recurrent respiratory infections. Physical examination findings: vital signs (heart rate, respiratory rate, blood pressure), growth parameters, pallor, edema, hepatomegaly, murmurs, signs of pulmonary congestion [5]. Investigations: chest X-ray, ECG, and echocardiography to confirm underlying cardiac lesions [4]. Classification of Heart Failure The Ross classification was used to assess the severity of CHF in infants, whereas older children were classified according to clinical severity based on symptoms, exercise tolerance, and signs of systemic congestion [6]. Data Analysis Data were entered into Microsoft Excel and analyzed using SPSS version 25.0. Descriptive statistics: mean ± standard deviation for continuous variables; percentages for categorical variables. Comparative analysis: Chi-square or Fisher’s exact test for categorical variables; independent t-test or ANOVA for continuous variables where appropriate. Significance level: p < 0.05 was considered statistically significant.

Demographic Profile

A total of 60 children with CHF were included in the study. The age distribution is shown in Table 1. The mean age was 3.8 ± 2.9 years. There were 35 males (58%) and 25 females (42%), giving a male-to-female ratio of 1.4:1.

Table 1: Age Distribution of Pediatric CHF Patients (n=60)

Etiology of Heart Failure

Congenital heart disease (CHD) was the most common cause, followed by dilated cardiomyopathy (DCM) and myocarditis.

Table 2: Etiology of Pediatric CHF (n=60)

Among CHD, ventricular septal defect (VSD) and patent ductus arteriosus (PDA) were the predominant lesions.

Clinical Presentation; - The common presenting symptoms included tachypnea, feeding difficulties, poor weight gain, and cough. Table 3 summarizes the findings.

Table 3: Clinical Features of Pediatric CHF (n=60)

Physical Examination Findings

Tachycardia: 90%

Displaced apical impulse: 40%

Rales / crepitations: 60%

Heart murmur: 65% (mostly due to underlying CHD)

Hepatomegaly: 75%

Severity of Heart Failure (Ross Classification)

Among infants (<1 year, n=18), CHF severity was assessed using the Ross classification:

Table 4: Ross Classification in Infants (<1 year, n=18)

Most infants presented with moderate to severe CHF (Ross class III–IV, 61%), reflecting late presentation and significant hemodynamic compromise.

Pediatric congestive heart failure (CHF) remains a significant cause of morbidity in children, with varied etiologies and clinical presentations depending on age and underlying pathology. In the present study, 60 children with CHF were analyzed to evaluate their demographic profile, etiology, clinical features, and severity.

In our study, the male-to-female ratio was 1.4:1, which is consistent with other reports suggesting a slight male predominance in pediatric CHF [7]. The mean age was 3.8 years, reflecting that CHF can present across all pediatric age groups, though infants and young children are more frequently affected due to the hemodynamic burden of congenital heart defects (CHD) [7,8].

Congenital heart disease was the leading cause of CHF in our cohort (58%), predominantly ventricular septal defects and patent ductus arteriosus, followed by dilated cardiomyopathy (20%) and myocarditis (10%). This aligns with previous studies indicating that structural heart disease accounts for the majority of pediatric CHF cases, while primary myocardial disease constitutes a smaller proportion [7,8]. Rheumatic heart disease, though less common in our study (8%), remains an important etiology in developing countries, particularly in older children [9].

Clinical features observed in our study were largely consistent with those described in the literature. Tachypnea (83%) and hepatomegaly (75%) were the most common signs, followed by feeding difficulty (70%), failure to thrive (63%), and peripheral edema (30%). These findings highlight that infants frequently present with pulmonary congestion and growth failure, whereas older children exhibit exercise intolerance and systemic venous congestion [7,10]. Notably, murmur was present in 65% of cases, reflecting the predominance of structural lesions in our cohort.

The Ross classification was used to assess severity among infants (<1 year). In our study, 61% of infants presented with moderate to severe CHF (Ross class III–IV), emphasizing the tendency for infants to manifest more pronounced clinical symptoms compared to older children [6,8]. Early recognition of such features is crucial to prevent further hemodynamic compromise and improve outcomes.

The demographic and clinical profile observed in this study is comparable with similar studies worldwide. For instance, Burch et al. reported that tachypnea, feeding difficulty, and hepatomegaly were the most frequent features among pediatric CHF patients, with CHD being the predominant etiology [7]. Macdonald et al. emphasized that myocardial dysfunction, although less frequent than CHD, often presents with more subtle symptoms such as fatigue, exercise intolerance, and growth retardation [8].

Our study reinforces the need for early identification of CHF based on clinical features, especially in infants, and the importance of echocardiography for definitive diagnosis and etiological classification. Early diagnosis facilitates timely medical management, surgical intervention when indicated, and improves prognosis.

Limitations

The study was single-center and had a limited sample size (n=60), which may not reflect the broader pediatric population.

Long-term follow-up data regarding outcomes after treatment were not included.

Laboratory markers of heart failure and biomarkers (e.g., BNP) were not systematically analyzed.

Pediatric CHF predominantly affects infants and young children, with CHD being the leading cause. Clinical manifestations vary with age, with tachypnea, hepatomegaly, and feeding difficulties being the most common findings. Recognition of these features, along with severity assessment using classifications such as the Ross score, is essential for early intervention and improved outcomes.

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