Heart Failure in Children: Symptoms, Causes, Diagnosis and Treatment

Heart failure in children is a serious cardiac condition that develops when the heart cannot pump the blood the body needs sufficiently and effectively. This condition presents with clinical findings such as growth retardation, feeding difficulty, respiratory distress, and getting tired quickly, and requires early diagnosis.

Symptoms of heart failure in children vary according to age and, especially in babies, appear with sweating during sucking, inability to gain weight, and rapid breathing. In older children, exercise intolerance, edema, abdominal swelling, and frequent lung infections are among the notable clinical indicators.

Causes of pediatric heart failure include congenital heart diseases, cardiomyopathies, rhythm disorders, and infectious conditions such as myocarditis. In addition, metabolic diseases, previously received chemotherapy, and genetic syndromes may also impair heart muscle functions and pave the way for the development of failure.

Treatment methods for heart failure in children are planned according to the underlying cause, and medical treatment constitutes the main approach. In medical treatment, ACE inhibitors, beta blockers, aldosterone antagonists, and diuretics are used, while in slightly older cases, some new drugs (such as ARB, ARNI, SGLT2 inh, ivabradine) are frequently used medications. In advanced cases, surgical interventions, mechanical support devices, and heart transplantation options are evaluated.

What You Need to Know	Information
Definition	Heart failure in children is a clinical condition that occurs when the heart cannot deliver the oxygen and nutrients the body needs to the tissues at a sufficient level. It may present with different symptoms in different age groups from the neonatal period to adolescence.
Incidence	It most commonly develops on the basis of congenital heart diseases and cardiomyopathies. It is seen more frequently in the neonatal and infancy periods due to congenital heart anomalies.
Symptoms in Newborns	Rapid breathing (tachypnea), getting tired quickly during feeding, sweating while sucking, bluish discoloration (cyanosis), inability to gain weight, restlessness, and weak sucking reflex may be seen.
Symptoms in Infancy	Feeding difficulty, insufficient weight gain, frequent lung infection, getting tired quickly, rapid breathing, and excessive sweating are common findings.
Symptoms in Older Children	Exercise intolerance, getting tired quickly, shortness of breath, swelling in the abdomen and legs (edema), palpitations, abdominal pain, and loss of appetite may be seen.
General Clinical Findings	Tachycardia (rapid heartbeat), hepatomegaly (liver enlargement), peripheral edema, fluid accumulation in the lungs, and an enlarged cardiac silhouette (cardiomegaly) may be detected.
Main Causes	Congenital heart diseases (ventricular septal defect, atrial septal defect, patent ductus arteriosus), cardiomyopathies, myocarditis, rhythm disorders, heart valve diseases, and some metabolic/genetic diseases are among the most common causes.
Risk Factors	A family history of heart disease, prematurity, genetic syndromes (for example Down syndrome), previous viral infections, and rheumatic diseases may pose a risk.
Diagnostic Methods	Physical examination, chest X-ray, electrocardiography (ECG), echocardiography (ECHO), blood tests (markers such as BNP), and cardiac MRI when necessary are used in diagnosis.
Laboratory Findings	Increased BNP or NT-proBNP levels, electrolyte imbalances, and kidney function disorders may be seen.
Medical Treatment	Diuretics (to reduce fluid overload), ACE inhibitors or ARBs (to reduce the workload of the heart), beta blockers, digitalis glycosides, and inotropic agents when necessary may be used.
Surgical Treatment	Surgical correction of the underlying congenital heart disease, valve repair/replacement, or heart transplantation in advanced cases may be performed.
Supportive Treatments	Oxygen support, nutritional support (high-calorie diet), fluid and salt restriction, and prevention of infections are important.
Complications	Growth retardation, recurrent lung infections, rhythm disorders, pulmonary hypertension, and multi-organ failure in advanced stages may develop.
Prognosis	Prognosis depends on the underlying cause, timing of diagnosis, and response to treatment. With early diagnosis and appropriate treatment, quality of life can be significantly improved in many children.
Prevention and Follow-up	Regular cardiological follow-up in at-risk children, protection from infections, appropriate vaccination, and family education are critically important for early intervention.

How Do the General Picture and the Causes of Heart Failure in Children Differ from Adults?

When heart failure is mentioned in adults, long-standing high blood pressure, vascular occlusions, previous heart attacks, or damage caused in the heart by unhealthy lifestyle habits usually come to mind. However, the situation encountered in childhood rises on a much different basis. In children, the source of the problem is largely congenital structural abnormalities, holes in the heart walls, underdeveloped heart chambers, or diseases that genetically affect the heart muscle.

A child’s heart is not just a small version of an adult heart. It is an extremely dynamic structure that is constantly growing, developing, and trying to adapt to the body’s increasing energy needs. Therefore, in pediatric cases, the way the disease appears, its rate of progression, and the treatment methods applied must be planned completely specifically according to that child’s age, weight, and developmental stage. The picture of failure that develops gradually over years in adults may appear much more rapidly and dramatically in children, especially in the first months of life.

What Are the Causes of Heart Failure in Children in the First Days of the Neonatal Period?

The first twenty-four hours of life are a very critical transition period in which a baby leaves the safe and externally dependent environment in the womb and begins to breathe and pump blood on its own. In heart failure conditions that suddenly develop in these first days, the problem is usually not a structural hole but rather the heart muscle losing its ability to contract under severe stress. The baby’s inability to receive enough oxygen during birth leads to serious damage and energy depletion in the not-yet-fully-mature heart muscle.

At the same time, metabolic crises such as a sudden drop in blood sugar or calcium levels in the body may also cut off the energy the heart needs and reduce its pumping power to zero. Some abnormalities in the structure of the blood, for example excessive thickening of the blood, cause the heart to strain excessively while pushing this dense fluid into the vessels and lead to failure.

The main problems that strain the heart in this very early period are as follows:

• Perinatal asphyxia
• Neonatal sepsis
• Hypoglycemia
• Hypocalcemia
• Severe anemias
• Hyperviscosity syndrome
• Congenital Heart Diseases

What Does Ductus Dependency Mean Among the Causes of Heart Failure in Children Seen in the First Week of Life?

While babies are in the womb, they do not use their lungs for breathing; they receive oxygen directly from the mother’s cord blood. During this period, there is a special bridge vessel that allows blood to be distributed directly to the body without going to the lungs. Shortly after birth, when the baby takes its first breath and the lungs fill with air, this bridge vessel is expected to close as a natural process.

However, in some congenital heart diseases, for example when there is severe narrowing or interruption in the aortic vessel, blood can reach the lower part of the body only through this open bridge vessel. When this vessel begins to close in the first week of life, blood flow to the body is suddenly interrupted. The baby rapidly enters a very severe condition called cardiogenic shock. In such situations, special drug infusions that keep this vessel open play a life-saving role until a surgical intervention is performed.

What Are the Causes of Heart Failure in Children During Infancy and Babyhood?

Within the first year of life, especially after the first month, the most common cause of heart failure is unwanted passages between the chambers of the heart. Large holes that cause clean blood on the left side of the heart to leak to the right side and from there back to the lungs are the leading actors of this period. As the pressure in the lung vessels naturally decreases in the first weeks after birth, blood chooses the easiest path and rushes through these holes toward the lungs.

This enormous blood volume going to the lungs eventually returns to the left side of the heart and leaves the heart with an excessive fluid load. The heart has to work constantly faster and stronger to pump this excess fluid to the body. Around the fourth to eighth weeks, the heart can no longer withstand this pace and signs of failure come to the surface. At the same time, rare but very dangerous anomalies such as coronary vessels that feed the heart arising from the wrong place may also cause the heart to be unable to receive nourishment and have a crisis during these months.

Congenital heart anomalies frequently encountered in this period are as follows:

• Ventricular septal defect
• Atrioventricular septal defect
• Patent ductus arteriosus
• Coronary artery anomalies
• Other than congenital heart diseases;
• Pneumonia
• Myocarditis
• Arrhythmias may cause heart failure.

Which Acquired Diseases Appear as Causes of Heart Failure in Older Children?

As children grow, problems that lead to heart failure move away from congenital structural holes and evolve toward acquired diseases and genetic disorders that directly affect the heart muscle. Acute rheumatic fever, which can develop after a simple throat infection, may leave permanent damage on the heart valves and cause the heart to leak blood or fail to pump fully.

Myocarditis conditions, in which viral infections directly settle in the heart muscle and create inflammation, may weaken the heart of a completely healthy child within days. In addition, cardiomyopathies that disrupt the structure of the heart muscle, cause it to lose its elasticity, or lead to excessive thickening are among the cornerstones of progressive failure during adolescence. Some powerful chemotherapy drugs used in children receiving cancer treatment are another important factor that requires very careful follow-up in this age group, as they may leave irreversible damage in the heart muscle.

Diseases encountered in older children are as follows:

• Acute rheumatic fever
• Kawasaki disease
• Viral myocarditis
• Dilated cardiomyopathy
• Hypertrophic cardiomyopathy
• Restrictive cardiomyopathy
• Drug-induced cardiotoxicity

What Effect Do the Body’s Defense Mechanisms Have on the Causes and Progression of Heart Failure in Children?

When the heart cannot pump enough blood, the body declares an emergency to protect vital organs such as the brain and kidneys. As the first response, the sympathetic nervous system is activated and a large amount of adrenaline is released into the blood. This adrenaline forces the heart to beat faster and stronger. Although this situation improves blood flow in the short term, in the long term, like a tired horse constantly being run, it completely depletes the oxygen reserves of the heart muscle and does not allow the heart to relax and rest.

At the same time, the kidneys, sensing that they are not receiving enough blood, think the body is dehydrated and trigger a hormonal chain that initiates salt and water retention. The amount of fluid in the vessels increases, the vessels narrow, and blood pressure is raised. It becomes much more difficult for the already tired heart to pump blood into narrowed pipes that are overly filled with fluid. When this hormonal bombardment continues for months, irreversible stiffening and deformities occur in the heart muscle.

What Are the Early Symptoms of Heart Failure in Children, Such as Getting Tired During Sucking?

Since babies cannot express the discomfort they feel with words, signs of heart failure usually show themselves through changes in feeding, growth, and daily routines. The most striking condition that parents may notice during this period is excessive difficulty during feeding. While feeding is an extremely effortless action for a healthy baby, for a baby with heart failure, sucking a bottle or breast is almost like performing heavy physical exercise.

The baby starts feeding with great appetite, but after a very short time, becomes breathless and has to stop sucking. After resting, the baby tries again but falls asleep from exhaustion before filling the stomach completely. During this difficult effort, due to excessive adrenaline secreted by the body, intense sweating begins especially around the baby’s forehead and head. The baby both cannot receive enough calories and expends excessive energy while feeding. This vicious cycle causes the child’s weight gain to stop and the child to fall behind peers.

The main problems observed in the early period are as follows:

• Sucking fatigue
• Frequent interrupted feeding
• Sweating in the forehead region
• Inability to gain weight
• Developmental stagnation

Which Symptoms of Heart Failure in Children Affect the Lungs and Respiratory System?

When the heart is insufficient in pumping oxygen-rich clean blood coming from the lungs to the body, this blood begins to pool backward in the thin vessels inside the lungs. This excess fluid leaking into the lung tissue narrows the airways and disrupts the spongy, elastic structure of the lungs. This condition gives very clear and distinct signs on the respiratory system.

Because the child can receive less oxygen, they begin to breathe much faster to compensate for this. With every breath, deep inward retractions are seen in the rib cage, between the ribs, and at the base of the neck. The baby breathes by opening the nostrils as wide as possible to draw in more air. As a result of the narrowing of the small airways in the lungs due to fluid pressure, wheezing breathing sounds similar to those heard in asthma attacks appear. Especially during sleep at night, choking-like coughing crises may occur due to increased fluid pooling in the horizontal position.

The main symptoms that appear in the respiratory system are as follows:

• Rapid breathing
• Rib cage retractions
• Nasal flaring
• Wheezing
• Intermittent nighttime cough

How Are Symptoms of Heart Failure Observed in Older Children Who Can Speak and Walk?

As the child grows and physical activities diversify, symptoms of heart failure become easier to identify. The most prominent complaint is quickly becoming exhausted and falling behind while playing in the park with peers or doing simple physical activities. Even a short run or climbing a few steps may cause the child to experience serious shortness of breath.

Due to weakness on the right side of the heart, blood this time accumulates backward in the body’s venous system. This situation affects the liver most; the outer membrane of the liver, which swells as it fills with blood, stretches, and this causes the child to complain of constant abdominal pain and loss of appetite. In advanced cases, with the effect of gravity, leaking fluids accumulate between tissues and create visible swelling, especially in the ankles and lower parts of the legs.

Findings encountered in older children are as follows:

• Getting tired quickly during exertion
• Shortness of breath increasing with movement
• Abdominal pain
• Loss of appetite
• Swelling in the ankles
• Prominence of the neck veins

How Are Blood Tests and Biomarkers Used in the Diagnosis of Symptoms of Heart Failure in Children?

In modern medicine, the diagnosis of heart failure is not made only with physical examination and a stethoscope; the chemical traces left by the heart in the bloodstream are sought with highly sensitive laboratory tests. Chief among these is a special hormone that the heart releases into the blood when it is excessively strained or when its walls have to stretch. Measuring the level of this hormone in the blood is almost like a liquid biopsy for detecting heart failure.

The amount of this protein-structured hormone in the blood reveals with mathematical certainty how much stress the heart is under at that moment. While these levels are quite low in a healthy heart, the values increase exponentially as the picture of heart failure becomes more severe. When the heart relaxes with the treatment applied and its workload decreases, these values in the blood also begin to fall rapidly. Therefore, these blood tests not only diagnose the disease but also serve as a perfect guide to monitor whether the medications given are working.

The main blood and laboratory parameters used are as follows:

• NT-proBNP and troponin levels
• Complete blood count
• Kidney function tests
• Liver enzymes
• Electrolyte levels

Why Are Echocardiography and Other Imaging Tools Important in Confirming Symptoms of Heart Failure in Children?

The most effective way to see what the problem in a child’s heart is anatomically and the working performance of the heart is imaging devices. In pediatric cardiology, the most basic and indispensable tool is echocardiography. This procedure, performed using sound waves, is completely painless, does not contain radiation, and reflects the valves, walls, holes, and direction of blood flow inside the heart on the screen within seconds.

With this method, the contractile power of the heart is calculated through percentage values. How much of the blood the heart chambers can eject forward with each beat is evaluated with millimetric measurements. If the abnormality in the heart is very complex or if how much damage the tissue of the heart muscle has sustained will be examined, then cardiac MRIs, which are a more advanced method, come into play. Thanks to this technology, possible edema, inflammation, or permanent scar tissue inside the heart muscle is mapped down to the finest detail.

Imaging tools used in the diagnosis and follow-up process are as follows:

• Echocardiography
• Cardiac magnetic resonance
• Myocardial perfusion scintigraphy
• Computed tomography
• Chest radiography
• Electrocardiogram

What Are the Treatment Methods for Heart Failure in Children Applied During an Acute Crisis Under Intensive Care Conditions?

At the moment of an acute crisis when the child’s heart suddenly loses its strength, cannot deliver enough blood to the organs, and the child is admitted to intensive care, the first goal of treatment is to rapidly stabilize vital functions. At this stage, since orally administered medications cannot act quickly enough, treatments are applied directly through the vein as continuous infusion.

The basis of treatment consists of medications that directly stimulate the heart muscle to contract more strongly and help blood flow forward more easily by dilating the vessels. These medications increase the pumping capacity of the heart within seconds, regulate blood flow to the kidneys and initiate urine output, and provide the time needed for the body to recover. However, because these agents are very powerful, they carry the risk of excessively accelerating the heart and causing rhythm disorders; therefore, their doses are given by being adjusted drop by drop with very sensitive devices.

The main intravenous drug groups used in intensive care are as follows:

• Positive inotropes
• Vasodilators
• Calcium sensitizers

How Do Treatment Methods for Heart Failure in Children That Remove Excessive Fluid Accumulation in the Body Work?

The most visible and most disturbing consequence of heart failure for the child is the accumulation of fluids unnecessarily retained by the body in the lungs, liver, and legs. Removing this fluid load from the body is equivalent to lifting the weight off the heart. For this purpose, diuretic medications that stimulate the kidneys and enable the patient to produce plenty of urine are one of the cornerstones of treatment.

These medications act on the filtering systems in the kidney tubules and ensure that excess salt and water in the body are rapidly excreted through urine. As fluid is removed, edema in the lungs resolves, the child’s breathing becomes easier, and the tension on the liver decreases. However, since some minerals that are very valuable for the body may also be lost during this intense fluid removal, additional medications that preserve mineral balance are included in the treatment scheme.

The main medications that provide fluid removal are as follows:

• Loop diuretics
• Thiazide group agents
• Potassium-sparing drugs
• ACE inhibitors / ARB / ARNI group medications

Which Medications Are Included in Treatment Methods for Heart Failure in Children That Continue at Home and Protect the Heart?

When the child overcomes the dangerous period in intensive care and becomes stable enough to return home, protective drug treatments that will prevent the heart from wearing out in the long term begin. This chronic period treatment aims to permanently prevent the body from activating the harmful defense mechanisms we mentioned earlier.

The production of hormones that constantly narrow the vessels and make the heart’s work harder is stopped with special medications. In this way, the vessels relax, the resistance in front of the heart disappears, and the heart becomes able to pump blood by expending much less energy. At the same time, the whipping effect of the adrenaline hormone on the heart is blocked with a different drug group. The heart rate is brought down to reasonable levels, the heart rests sufficiently between each beat, and it has the time needed to fill itself with fresh blood. Thanks to these medications, the enlargement and deformation of the heart over time can be stopped.

The main drug groups used in home treatment are as follows:

• ACE inhibitors / ARB group medications
• Beta blockers
• Mineralocorticoid receptor antagonists (Spironolactone)
• SGLT-2 inhibitors (such as Dapagliflozin (Forxiga), Empagliflozin (Jardiance))
• Sacubitril valsartan (ARNI)

What Do Device-Supported Treatment Methods for Heart Failure in Children Offer in Cases Where Medications Are Insufficient?

Even the strongest medication combinations offered by modern medicine may sometimes not be enough to recover an extremely exhausted heart. When the heart reaches the point where it cannot meet even the minimum needs of the body, advanced technologies known as mechanical support devices act as a life-saving bridge.

These devices are artificial pump systems that partially or completely take over the function of the child’s own heart even if it has not completely stopped. In very severe and sudden crises, systems that take blood from outside the body, oxygenate it, and return it reduce the load of both the lungs and the heart to zero, giving the organs time to heal. In situations requiring longer-term support, artificial mechanical heart pumps that are placed directly inside the heart and pump blood into the vessels are used. These devices normalize organ perfusion and prepare the child for the next major step in a healthier way.

The mechanical support systems used are as follows:

• Extracorporeal membrane oxygenation (ECMO)
• Left ventricular assist devices (L-VAD)
• Right ventricular assist devices
• Biventricular support systems

What Is the Place of Heart Transplantation Among Treatment Methods for Heart Failure in Children Known as the Most Advanced Stage?

In end-stage heart diseases where all medical and device-supported treatment efforts have reached the point of exhaustion, the only definitive permanent solution is heart transplantation. In cases of congenital anomalies too complex to be repaired or when the heart muscle has completely lost its function, a new and healthy heart means a brand-new beginning for the child. However, the difficulty of finding a suitable organ requires recipient candidates to go through a very detailed preparation and selection process.

Even after the transplant surgery is successful, the real struggle begins with the immune system. The body will perceive this new heart as a structure that does not belong to itself and will want to attack it. To prevent this, special lifelong immunosuppressive treatments come into play. It is vitally necessary for families to know the signs of organ rejection very well and to apply to a healthcare institution if the child feels even the slightest fever or fatigue.

The main elements that should be considered in the transplantation process are as follows:

• Organ compatibility tests
• Immunosuppressive medication regimen
• Protection from infections
• Regular biopsy follow-ups

How Should Treatment Methods for Heart Failure in Children Applied at Home After Discharge from the Hospital and the Nutritional Regimen Be?

The treatment of a child with heart failure is not considered finished when leaving the hospital door; the real process begins with the devotion and careful care that the family will show at home. One of the most critical pillars of home care is the child’s nutrition. Since the hearts of these children constantly work at a high pace, the amount of calories they burn daily is much higher than that of healthy peers. In order for them to close this gap with their small stomach volumes, they need to be fed with specially formulated formulas or enriched foods with concentrated calories and energy. Weighing the child regularly every day and monitoring weight gain is the most practical home compass showing the success of treatment.

Physical activities should not be completely prohibited; playing games is necessary for the child’s socialization and psychological development. However, instead of competitive activities that will overly tire the heart and require sudden sprints or long-term exertion, games in which the child determines their own pace should be preferred. Families should encourage their children to rest as soon as they understand that they are tired. Thanks to correct medication use, careful nutrition, and close doctor-family communication, a very large proportion of these children can live an extremely happy and active life.

Daily routines that should be carefully applied at home are as follows:

• Daily weight measurement
• Calorie-rich nutrition
• Compliance with medication times
• Games with exertion restriction
• Protection from frequent infections
• Completion of vaccinations and missing vaccines