Pediatrics · MU Sofia

19. Heart failure in children. Myocarditis in children

Covers heart failure in children, from its main causes by age, through its presentation, severity grading and investigations, to the treatment goals and measures. It then turns to myocarditis, listing viral and other triggers, the clinical picture, tests and treatment, and closes with a short summary of cardiomyopathies and dental considerations. Two tables summarise age-related causes and treatment measures, and the Ross and NYHA classifications are named.

Inside: 6 sections · 2 tables · 16 flashcards · 4 min

Topic 19 of 30 in the MU Sofia syllabus for Pediatrics (Medicine, Year 5). The free AceMed note covers it in 6 sections, about 441 words (4 min of reading), with 16 flashcards.

In this note

  1. Introduction
  2. Causes by age
  3. How it shows
  4. Treatment
  5. Myocarditis
  6. Cardiomyopathies (brief)

Introduction

Heart failure is when the heart cannot pump enough blood for the body's needs, or can only do so at high filling pressures. In adults it is mostly ischaemic; in children it is mostly from congenital heart defects in infancy and from heart muscle disease (cardiomyopathy, myocarditis) later.

How it shows

  • Infants: fast breathing, sweating and tiring during feeds, poor weight gain, irritability, tachycardia, gallop rhythm, enlarged liver (the most reliable sign). Peripheral oedema is rare in infants.
  • Older children: exercise intolerance, breathlessness lying flat, cough, abdominal pain, oedema, raised jugular venous pressure, crackles.
  • Severity: Ross classification (I none – IV symptoms at rest) in infants and young children; NYHA in older ones.

Tests: chest X-ray (big heart: cardiothoracic ratio over 0.6 in infants, 0.5 in older children; plethoric lungs), ECG, echocardiography (structure, ejection fraction), NT-proBNP, blood gases, electrolytes, renal function.

Myocarditis

Inflammation of the heart muscle, usually viral: enteroviruses (Coxsackie B), adenovirus, parvovirus B19, HHV-6, influenza, SARS-CoV-2 (also the multisystem inflammatory syndrome, MIS-C). Rarely after mRNA vaccines (mostly teenage boys, mild), drugs, autoimmune diseases, or giant-cell myocarditis.

Presentation

  • A few days after a cold or gastroenteritis: tiredness, breathlessness, vomiting, tachycardia out of proportion to the fever, chest pain (teenagers).
  • Range: mild to fulminant (cardiogenic shock in hours), arrhythmias, heart block, sudden death.
  • In infants it is easily mistaken for bronchiolitis or sepsis: look for a big liver, gallop and a big heart on X-ray.

Tests

  • Troponin raised; NT-proBNP raised.
  • ECG: sinus tachycardia, low voltages, ST-T changes, arrhythmias, AV block.
  • Echo: poor function, dilated left ventricle, mitral regurgitation, effusion.
  • Cardiac MRI (oedema and late gadolinium enhancement: Lake Louise criteria); endomyocardial biopsy (the gold standard) is rarely needed. Viral PCR.

Treatment

  • Supportive heart failure treatment; inotropes, ventilation, ECMO or VAD for fulminant cases (many recover).
  • IVIG is often given (evidence limited); immunosuppression for specific types (giant-cell, autoimmune).
  • Treat arrhythmias; a temporary pacemaker for complete heart block.
  • No competitive sport for 3–6 months, until tests are normal.

Outcome: roughly a third recover fully, a third keep some dysfunction (dilated cardiomyopathy), and a third need a transplant or die; fulminant myocarditis that survives the acute phase often recovers well.

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