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The term heart failure describes a heart that’s not functioning properly. It does not mean that the heart has stopped working but instead that it isn’t working as well as it should.

Heart failure occurs in adults due to effects of smoking, high blood pressure, diabetes and coronary artery disease. It can occur in newborns, infants, toddlers and teenagers for other reasons.

Since heart failure has different causes, it’s important to recognize how it’s diagnosed, treated and even cured in younger children. But to understand how heart failure presents itself in children, it’s important to first know how a heart should work. 

The healthy heart

The heart is a pump. Its pumping function is initiated by an internal electrical system. A healthy heart is cleanly divided into a right and left side, each with an upper and lower section. All of these compartments have an important job in helping circulate blood carrying the oxygen we breathe to the body by moving it through the heart and lungs in a certain order and direction. 

A wall, called a septum, separates the two sides of the heart so that the blood with oxygen from the lungs and the blood without oxygen do not mix. Valves help the heart’s sides and sections circulate blood in the heart in the right  direction to move oxygen-poor blood to the lungs and move oxygen-rich blood to the rest of the body. Valves do this by preventing the backward flow of blood inside the heart.

For a child to grow and develop, the heart needs to maintain normal pump function in order to provide effective blood flow throughout the body. 

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What causes heart failure in children?

Heart failure in children is most often caused by congenital heart defects, meaning defects present at birth. Sometimes, certain medical disorders can cause children to develop heart defects or can damage a child’s heart, which causes heart failure.

Types of pediatric heart failure

Over-circulation failure

Some congenital heart defects that can cause heart failure in children include those that interrupt the clean division of the heart’s chambers. These defects interrupt the normal blood flow through the heart, meaning the heart cannot circulate blood properly. These defects cause a type of heart failure called over-circulation failure, which is when oxygenated and de-oxygenated blood mix inside the heart rather than remaining separate to circulate through the body properly. These defects include:

• A hole between the right or left upper or lower chambers.
• Incorrectly formed heart chambers.
• Defective major arteries.
• Leaky or narrowed heart valves.

Pump failure

Some medical conditions can cause a child’s heart to develop incorrectly or become damaged. This leads the heart to pump ineffectively, which is called pump failure.

Pump failure can be caused by:

• A viral or bacterial infection that damages otherwise normal heart muscle.
• Decrease in the blood supply to the heart (rare in children).
• Certain medications to treat other medical conditions such as cancer.
• Irregular heartbeats, which happen when the heart’s electrical system is either abnormal from birth or damaged by infection, causing the heart to beat too slow or too fast.
• Heart valve defects in which a valve does not open or close properly, causing pressure to back up inside the heart chambers.
• Children with health conditions such as muscular dystrophy, Kawasaki disease or specific genetic disorders can eventually also develop problems with the heart muscle. 

Signs and symptoms

Infants

In infants, signs and symptoms of heart failure include:

• Breathing trouble.
• Poor feeding.
• Poor growth.
• Excessive sweating.
• Swelling of the feet, ankles, lower legs, belly, face or neck.

Often, an infant with heart failure will:

• Take longer to feed or become uninterested in feeding after a short time.
• Have a rapid heartbeat that can be felt through the chest wall when the infant is sleeping or resting.
• Not gain weight at a healthy rate.
• Experience rapid or labored breathing.

Children

Children and teenagers with heart failure can:

• Become tired quickly, especially if a viral infection has caused heart muscle damage.
• Urinate more frequently at night.
• Lose their appetite.
• Cough.
• Experience an irregular heartbeat.
• Have swelling in the feet, ankles or abdomen.
• Gain weight.
• Experience shortness of breath.      

Diagnosis

Examination

If heart failure is suspected for your child, your child’s health care professional will examine them for:

• Rapid or labored breathing.
• Swelling in their feet, ankles and abdomen.
• Neck veins that stick out.
• Crackles in your child's lungs from fluid buildup.
• Irregular heartbeat or heart sounds.

Your child’s health care professional might also take a blood sample from your child to send to a lab to look for signs of heart failure.

Imaging

If your child’s physician suspects that your child might be experiencing heart failure, they will  order imaging to look at your child’s heart.

Imaging can include:

• Electrocardiogram (EKG or ECG) to evaluate the heart rhythm.
• Ultrasound of the heart (echocardiogram) to evaluate heart structure and function.
• Chest X-ray to help determine if the heart is enlarged.

Your child could be referred to a pediatric heart specialist for imaging or for additional tests, but imaging is typically performed in the pediatrician’s office or clinic. Imaging is not painful. However, depending on your child’s age and ability to cooperate, light sedation might be necessary for the clearest results.

Testing

At times, a heart catheterization might be required. In this test, a small plastic tube, called a catheter, is placed inside the heart from a blood vessel in your child’s leg or arm. The catheter is used to record pressures and the amount of oxygen in the different parts of the heart. Because this test is performed in a special catheterization procedure room or laboratory, a short hospital admission is often necessary.

How is pediatric heart failure treated?

Treating over-circulation failure

Often, over-circulation failure can be managed with medications. Sometimes, your child’s health care professional might initially treat your child with medications that require hospitalization. The medications can include diuretics (water pills) and afterload reducers, which can help unload the excessive volume in your child’s heart, lower blood pressure resistance and improve the heart’s ability to circulate blood.

Your health care professional might consider nutritional supplements to help your child get enough calories to offset the effects of over-circulation.

However, the defect causing your child’s heart failure might be too difficult to manage with medications and nutritional changes. Surgery is often necessary to repair the defect causing over-circulation failure. If heart surgery is required, you will have the opportunity to discuss the types of surgery or other treatments that are available with your child’s health care professional.

Treating pump failure

If your child’s heart failure is caused by pump failure, diuretics and afterload reducers may be used. Sometimes other medications can be prescribed that lower blood pressure to help the heart pump better. Hospitalization can be necessary to further improve heart function. At times, surgery can also be required, such as replacing a damaged heart valve.

Pump failure caused by a heartbeat that is too slow often requires a pacemaker. Pacemakers are implanted medical devices that help the heart maintain a normal heart rate. The small, battery-operated devices are tiny computers implanted under your child’s skin with a small wire connected to the heart. This requires a surgical procedure.

If the pump failure is caused by a heartbeat that is too fast, your child might need medications to control the heartbeat. At other times, a specialized heart catheterization procedure called radiofrequency ablation  might be recommended  to correct the abnormal heart rhythm. This procedure applies short bursts of radio waves to the area of heart muscle causing the rapid heartbeat.

Rarely, if pump failure is caused by irreversible muscle damage, heart function could not improve with medication and could continue to worsen. In this situation, a special pacemaker, mechanical pump (LVAD) or an extracorporeal membrane oxygenator (ECMO) might be necessary to improve  heart pump function temporarily. If heart muscle function continues to deteriorate despite therapy, your heart specialist might discuss the need for a heart transplant.

Room for optimism

Although heart failure can happen to any child, it is extremely rare and not necessarily a hopeless condition. Many of the causes of pediatric heart failure can be repaired or managed. It’s important that parents and family members understand the causes and treatments of heart failure in children.

When parents ensure that proper medical care is provided, and as newer techniques and medications become available, most children with heart failure should be able to grow and lead active lives.