Heart disease in children are usually birth defects, that means that there has been some abnormality in the normal development of the heart in fetal life. These defects are commonly called congenital heart defects (CHD). Acquired heart disease is disease that affects a normal heart in later life. They are relatively less common in young children. Congenital heart disease has an incidence of about 8/1000 new births, that means that if you have a newborn there is approximately a little less than 1% chance of the child having a congenital heart defect. Although the percentage is low, given the large population and birth rate in our country, it translates to about 2,25,000 newborns having CHD every year. The heart being the organ that controls the life sustaining blood circulation in the body, it is understandable that a normally functioning heart is essential for a normal quality and length of life. Congenital defects of the heart will affect the lifespan of the newborn depending on the type and severity of the defect. Many many different types of defects can occur in the heart – some simple and some very complicated. Simple defects may allow normal growth for many years and may not be diagnosed in early life. Complicated defects will not allow the baby to survive long after birth and so are likely to be diagnosed earlier
The majority of heart defects can be treated today by surgery or nonsurgical interventions, allowing these children to lead normal lives. It is important therefore that the heart condition is diagnosed in time and treated in. a timely fashion. So, the question arises in a parent’s mind – How do I suspect that my child has heart disease?
There are many stages in which congenital heart defects can be picked up. Fetal ultrasound is routinely performed nowadays by obstetricians to monitor fetal growth. They may pick up some tell-tale signs of a heart defect and refer the mother to a pediatric cardiologist for a more detailed fetal cardiac echocardiogram. The fetal heart is almost fully developed by 16 weeks of pregnancy and at this staged a trained pediatric cardiologist can make a reasonable diagnosis of a heart defect, if present. The cardiologist can then advise the further course of management depending on the diagnosis.
More often than not, heart defects will get suspected and diagnosed only after birth. Critical defects will cause symptoms soon after birth. The newborn may have difficulty breathing, may turn blue or show poor activity. Such babies need immediate resuscitation in the neonatal ICU and will have an urgent echocardiogram to establish the diagnosis. In babies who are otherwise well, it is routine to check the body oxygen level with a pulse oximeter. A lower-than-normal oxygen saturation may indicate a cyanotic variety of CHD. Neonatologists will also check the pulses in all the four limbs. If the pulses in the lower limbs are feeble then that points towards a condition called coarctation of the aorta which is a congenital narrowing of the main artery to the body – the aorta.
Most babies with heart defects will escape recognition of the defect at this stage because the shift of circulation from fetal life to postnatal life takes a few days. As the child grows symptoms slowly start, and it will be up to the astute parent or pediatrician to pick up the early signs of trouble. None of the symptoms are diagnostic of heart disease, but their presence should warrant further investigation to exclude heart disease.
Some of the common symptoms in infants are listed below:
1. Poor feeding – the baby stops frequently to rest during feeds or does not take the full feed at one go. Poor weight gain results as a consequence of this.
2. Excessive crying, sweating and fast breathing.
3. Mother may notice a fast heart beat or excessive thumping of the heart when she holds the baby against her chest.
4. Blueness of the lips, tongue and finger nails especially during crying.
5. Frequent illnesses especially with cough and chest congestion
6. The pediatrician may pick up abnormal heart sounds – called murmurs while performing a routine health check or examining for an unrelated complaint. Often a chest x-ray performed for a chest infection shows up an enlarged heart shadow or abnormal lung markings which point towards an underlying CHD.
Older school going children will have other indicators that may suggest a heart problem. Some of these are: 1. Poor weight gain – in comparison to the siblings or others in the same class.
2. Getting tired easily, inability to keep up with the classmates in games or sports.
3. Blueness of the fingers and nails especially during play or activity.
4. Frequent episodes of pneumonia.
5. Episodes of giddiness or fainting
6. Some children may even complain of excessive palpitation even with low level of activity.
7. Routine health check-ups in school have also resulted in heart disease being picked up. Most of these symptoms and signs pertain to congenital heart disease. As stated earlier, children can also have acquired heart disease.
The common forms of acquired heart disease are:
1. Rheumatic heart disease: This results from an inflammation of the heart valves as a response to throat infection with streptococcus bacteria. During the acute phase the child may have fever and pain in the large joints. In the chronic phase the heart valves are affected leading to narrowing or leakage. The symptoms then are those of heart failure – tiredness, fast breathing, palpitations and poor weight gain.
2. Infective endocarditis: This is infection within the heart usually affecting the heart valves. This usually occurs if here is an underlying abnormality in the heart which allows an infection from elsewhere to take root in the heart. This condition is difficult to treat if not picked up early and has a significant risk to life. Persistent fever not responding to medical treatment is the hallmark. An echocardiogram will usually pick up signs of infection in the heart and repeated blood cultures are needed to isolate the organism causing the infection. So, a cardiac checkup is always advisable in any child with fever without an obvious cause lasting over two weeks.
3. Viral myocarditis: Certain viral infections can damage the heart muscles and produce severe weakening if the heart function. The child will again have all the symptoms of heart failure and an echocardiogram will confirm the diagnosis
4. Kawasaki’s disease: This is an inflammatory disorder that affects many systems in the body including the heart. The arteries of the heart – coronary arteries are mainly involved. There are no specific symptoms but this is one of the conditions that pediatricians will keep in mind when investigation unusual presentations of fever.
Chest pain is not a common symptom in children with heart disease, unlike in adults where it is almost always associated with a diagnosis of heart disease. In adolescents and teenagers recurrent chest pain needs investigation since it may result from a rare abnormality of the origin and course of coronary arteries. This condition has been linked to the reported incidents of sudden collapse and even death of young athletes and sportspersons.
Children can also have disorders of the heart rate and rhythm. The heart rate can be unusually fast or unusually slow. Fast heart rate may manifest as palpitations and may occur episodically. Slow heart rates can result from a defect in the electrical conduction system of the heart and can present as fainting episodes. A routine ECG can diagnose most of these disorders and usually consultation with an electrophysiologist would be suggested to guide treatment.
Three basic investigations are generally performed for evaluation of a child with suspected heart disease – ECG, Chest X-ray and Echocardiogram. It is important that the child is evaluated by a trained pediatric cardiologist so that a proper diagnosis is made and a proper advice on the treatment is provided.
The diagnosis of heart disease in a child can come as a shock to the parents who tend to immediately have visions of doomsday. However, that is not so in today’s age. Most heart disorders in children are amenable to treatment and so there is no need for parents to despair.
DR KRISHNA IYER
M.B.B.S., M.S., M.Ch.(CTVS, AIIMS, New Delhi)
Pediatric & Congenital Heart Surgery