Congestive heart failure (peds)

This page is for pediatric patients. For adult patients, see: congestive heart failure


  • Pediatric congestive heart failure (CHF) affects 12,000-35,000 children in the United States each year[1]
  • The causes and clinical presentation varies differently compared to adults


Clinical Features


  • Difficulty breathing
  • Feeding difficulty - irritability with feeding, prolonged feeding time, refusal to feed
    • If an infant has to decide between feeding and breathing, he/she will choose to breathe
  • Sweating with feeds
    • "Exercise intolerance"
  • Failure to thrive
  • Fussiness
  • Older children: fatigue, exercise intolerance, dyspnea, orthopnea, abdominal pain, dependent edema[3]

Physical Exam

  • Tachycardia
  • Tachypnea with labored breathing and accessory muscle use
  • Grunting with nasal flaring
  • Rales
  • S3 gallop
  • Hepatomegaly
  • Cyanosis, cool/mottled extremities
  • Decreased capillary refill
  • Edema of face and limbs

Differential Diagnosis



Other diseases with abnormal respiration



  • Blood Work
    • CBC
    • BMP
    • Mg
    • LFT
    • BNP
    • Troponin
    • Blood gas
    • Inflammatory markers such as ESR/CRP if concern for myocarditis, although these are nonspecific
  • EKG
    • Sinus tachycardia - most common
    • May find other etiologies to CHF such as ECG abnormalities pointing towards myocarditis, restrictive cardiomyopathy, heart block, arrhythmias
  • CXR
    • Will help assess for cardiomegaly, pulmonary congestion, interstitial edema, pleural effusions


Lung ultrasound of pulmonary edema

Lung ultrasound showing pulmonary edema.
  • A lines and B lines
    • A lines:
      • Appear as horizontal lines
      • Indicate dry interlobular septa.
      • Predominance of A lines has 90% sensitivity, 67% specificity for pulmonary artery wedge pressure <= 13mm Hg
      • A line predominance suggests that intravenous fluids may be safely given without concern for pulmonary edema
    • B lines ("comets"):
      • White lines from the pleura to the bottom of the screen
      • Highly sensitive for pulmonary edema, but can be present at low wedge pressures


Goal in heart failure management is to reduce preload (EDV), to reach higher SV on Frank Starling curve.
  • Management tailored to severity of disease
  • Noninvasive ventilation
    • HFNC
    • CPAP
    • BiPAP
  • Diuretics
  • Inotropes/Catecholamines
    • To be used if cardiac function significantly depressed
    • Dopamine (preferred drug for decompensated CHF)
    • Low dose Epinephrine for refractory hypotension
  • Pediatric Cardiology consult


  • In general CHF exacerbation will require admission
  • NICU/PICU if unstable

See Also

External Links


  1. Rossano JW, Kim JJ, Decker JA, et al. Prevalence, morbidity, and mortality of heart failure-related hospitalizations in children in the United States: a population-based study. J Card Fail 2012; 18:459
  2. Judge et al. Congenital Heart Disease In Pediatric Patients: Recognizing The Undiagnosed And Managing Complications In The Emergency Department. Pediatr Emerg Med Pract. 2016. May;13(5):1-28
  3. Jayaprasad. Heart Failure in Children. Heart Views. 2016 Jul-Sep;17(3):92-99