Chapter 4.8 Heart failure

Heart failure causes fast breathing and respiratory distress. The underlying causes include congenital heart disease (usually in the first months of life), acute rheumatic fever, cardiac arrhythmia, myocarditis, suppurative pericarditis with constriction, infective endocarditis, acute glomerulonephritis, severe anaemia, severe pneumonia and severe malnutrition. Heart failure can be precipitated or worsened by fluid overload, especially when large volumes of IV fluids are given.


The commonest signs of heart failure, on examination, are:

  • tachycardia (heart rate > 160/minute in a child < 12 months old; >120/minute in a child aged 12 months to 5 years).
  • gallop rhythm with basal crackles on auscultation.
  • enlarged, tender liver.
  • in infants—fast breathing (or sweating), especially when feeding; in older children, oedema of the feet, hands, or face or distended beck veins (raised jugular venous pressure).
  • Severe palmar pallor may be present if severe anaemia is the cause of the heart failure.
  • Heart murmur may be present in rheumatic heart disease, congenital heart disease or endocarditis.
  • If the diagnosis is in doubt, a chest X-ray can be taken and may show an enlarged heart or abnormal shape.
  • Measure blood pressure if possible. If it is raised, consider acute glomerulo-nephritis (See standard paediatric textbook for treatment).


Treatment depends on the underlying heart disease (Consult international or national paediatric guidelines). The main measures for treating heart failure in children who are not severely malnourished are:

  • Oxygen. Give oxygen if the child has a respiratory rate of > 70/min, shows signs of respiratory distress, or has central cyanosis or low oxygen satura-tion. Aim to keep oxygen saturation > 90%
  • Diuretics. Give furosemide: A dose of 1 mg/kg should increase urine flow within 2 h. For faster action, give the drug IV. If the initial dose is not effecTive, give 2 mg/kg and repeat in 12 h, if necessary. Thereafter, a single daily dose of 1–2 mg/kg orally is usually sufficient.
  • Digoxin. Consider giving digoxin (see Annex 2).
  • Supplemental potassium. Supplemental potassium is not required when furosemide is given alone for treatment lasting only a few days. When digoxin and furosemide are given, or if furosemide is given for more than 5 days, give oral potassium at 3–5 mmol/kg per day.

Supportive care

  • Avoid giving IV fluids, if possible.
  • Support the child in a semi-seated position with head and shoulders elevated and lower limbs dependent.
  • Relieve any fever with paracetamol to reduce the cardiac workload.
  • Consider transfusion if severe anaemia is present.


The child should be checked by a nurse every 6 h (every 3 h while on oxygen therapy) and by a doctor once a day. Monitor both respiratory and pulse rates, liver size and body weight to assess the response to treatment. Continue treatment until the respiratory and pulse rates are normal and the liver is no longer enlarged.