Pediatric Congestive Heart Failure Clinical Presentation

Updated: May 03, 2015
  • Author: Gary M Satou, MD, FASE; Chief Editor: Stuart Berger, MD  more...
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Thorough history taking and physical examination, including an assessment of the upper-extremity and lower-extremity blood pressures, are crucial in the evaluation of an infant or child with congestive heart failure.

Regardless of the etiology, the first manifestation of congestive heart failure is usually tachycardia. An obvious exception to this finding occurs in congestive heart failure due to a primary bradyarrhythmia or complete heart block.

As the severity of congestive heart failure increases, signs of venous congestion usually ensue. Left-sided heart failure is generally associated with signs of pulmonary venous congestion, whereas right-sided heart failure is associated with signs of systemic venous congestion. Marked failure of either ventricle, however, can affect the function of the other, leading to systemic and pulmonary venous congestion.

Later stages of congestive heart failure are characterized by signs and symptoms of low cardiac output. Generally, congestive heart failure with normal cardiac output is called compensated congestive heart failure, and congestive heart failure with inadequate cardiac output is considered decompensated.

Signs of congestive heart failure vary with the age of the child. [5] Signs of pulmonary venous congestion in an infant generally include tachypnea, respiratory distress (retractions), grunting, and difficulty with feeding. Often, children with congestive heart failure have diaphoresis during feedings, which is possibly related to a catecholamine surge that occurs when they are challenged with eating while in respiratory distress.

Right-sided venous congestion is characterized by hepatosplenomegaly and, less frequently, by edema or ascites. Jugular venous distention is not a reliable indicator of systemic venous congestion in infants, because the jugular veins are difficult to observe. In addition, the distance from the right atrium to the angle of the jaw may be no more than 8-10 cm, even when the individual is sitting upright.

Uncompensated congestive heart failure in an infant primarily manifests as a failure to thrive. In severe cases, failure to thrive may be followed by signs of renal and hepatic failure.

In older children, left-sided venous congestion causes tachypnea, respiratory distress, and wheezing (cardiac asthma). Right-sided congestion may result in hepatosplenomegaly, jugular venous distention, edema, ascites, and/or pleural effusions.

Older children with uncompensated congestive heart failure may have fatigue or lower-than-usual energy levels. Patients may complain of cool extremities, abdominal pain, nausea/vomiting, exercise intolerance, dizziness, or syncope.


Physical Examination

Clinical findings may include hypotension, cool extremities with poor peripheral perfusion, a thready pulse, and decreased urine output. Chemical evidence of renal and liver dysfunction may be present, as well as a diminished level of consciousness. Children with uncompensated congestive heart failure, particularly older children, generally have a lower cardiac output than that which most experienced clinicians would estimate on the basis of the clinical signs.

Signs and symptoms of congestive heart failure include the following:

  • Tachycardia
  • Venous congestion - Right-sided (hepatomegaly, ascites, abdominal pain, pleural effusion, edema, jugular venous distention); left-sided (tachypnea, retractions, nasal flaring or grunting, rales, pulmonary edema)
  • Low cardiac output - Fatigue or low energy, pallor, sweating, cool extremities, nausea/vomiting, poor growth, dizziness, altered consciousness, and syncope