pediatrics 3

Earliest Signs of Heart Failure in Infants

  • Tachycardia: A heart rate of greater than 160 beats per minute resulting from sympathetic nervous system stimulation.
  • Summation Gallop: A heart sound indicating excessive preload dilation.
  • Diaphoresis: Notable sweating, especially during exertion, often seen in infants as a sweaty scalp.
  • Slow Capillary Refill: A sign of decreased cardiac output.
  • Low Blood Pressure: Indicative of poor cardiac function.
  • Modeling: Skin changes that signal decreased perfusion.

Importance of Feeding Position

  • Upright Position for Feeding: Critical for infants with heart failure to reduce stomach and diaphragm compression.
    • Proper Positioning:
    • Infants should be held upright while feeding to allow better cardiovascular function.
    • Improves oxygenation and feeding efficiency.
  • Consequences of Incorrect Positioning:
    • Feeding while lying flat can lead to:
    • Ear infections
    • Tooth decay
    • Aspiration
    • Overeating
    • Less bonding time with caregivers
    • Challenge of sucking air during feeding reduces nutritional intake.

Monitoring and Feeding Challenges

  • Increased Respiratory Rate (Tachypnea): Greater than 60 breaths per minute.
  • Symptoms of Pulmonary Congestion include:
    • Dyspnea that compromises feeding and leads to poor weight gain and failure to thrive.
  • Nutritional Requirements:
    • Infants may need nasogastric feeding or concentrated formulas if they cannot consume sufficient calories within thirty minutes of feeding every three hours.

Symptoms of Congestion

  • Pulmonary Venous Congestion Symptoms:
    • Tachypnea, dyspnea, poor weight gain, failure to thrive.
  • Systemic Venous Congestion Symptoms:
    • Edema: Sacral, scrotal, and periorbital.
    • Visible neck veins in older children leading to ascites, pleural effusion, and overall weight gain.

Decreasing Cardiac Workload

  • Strategies to alleviate heart workload:
    • Limit feeding times.
    • Elevate the head during rest.
    • Encourage infant to engage in self-limiting activities.
    • Administer oxygen as necessary based on the lesion type.

Educating Parents and Caregivers

  • Essential topics to cover include:
    • Recognizing signs and symptoms of heart failure.
    • Approaches to handling increased cyanosis (knees to chest position).
    • Preventing dehydration and infection.
    • Recognizing dysrhythmias and appropriate intake adjustments.
    • Understanding when to contact a cardiologist.

Postoperative Management

  • Key focus areas:
    • Monitoring cardiac output: blood pressure and mean arterial pressure (MAP).
    • Maintaining respiratory function, with plans for intubation initially.
    • Monitoring fluid and electrolyte balance (strict intake and output monitoring with a Foley catheter).
    • Supporting comfort: repositioning, sedatives like Versed and Fentanyl as needed.

Goals for Collaborative Care

  • Goals include:
    • Improving cardiac output by:
    • Decreasing preload (reducing fluid volume returning to the heart).
    • Decreasing afterload (facilitating heart pumping).
    • Increasing contractility (enhancing heart strength) using medications like digoxin.
  • All interventions aim to reduce cardiac oxygen demand.

Digoxin Use in Infants

  • Mechanism: Digoxin increases heart contractility by slowing the heart rate for more effective pumping.
  • Dosing Protocol:
    • Dosage: No more than fifty micrograms. Check the apical pulse for one minute prior to administration.
    • Administer orally one hour before feeding or two hours after for optimal effect.
  • Therapeutic Window: Digoxin has a narrow therapeutic range, increasing the risk of underdosing or overdosing.
  • Signs of Toxicity:
    • Vomiting as a response to overdose.
    • Bradycardia and poor feeding experiences.
  • Antidote: Digibind may be administered to treat digoxin toxicity.

Diuretics in Cardiac Care

  • Commonly used diuretics include:
    • Lasix and Thiazides.
  • Important considerations:
    • Monitor for fluid restrictions, especially in children with polycythemia.
    • Sodium restriction through dietary measures (e.g., avoiding added salt).
    • Regularly record intake and output and weigh children daily.
    • For toilet-trained children, administer diuretics during the day to avoid nocturnal bedwetting.
  • Potassium Monitoring:
    • Encourage high potassium foods (bananas, potatoes, and oranges).

General Care for Cardiac Infants

  • Ensure infants do not experience extreme temperatures, treating signs of infection promptly.
  • Maintain a routine of sleep and activity to avoid exertion.
  • Protect skin integrity through use of special mattresses and frequent repositioning to prevent sores.
  • Consider special nipples to reduce sucking effort.
  • Establish a feeding schedule every three hours and maintain an upright feeding position.
  • Enhanced Caloric Formula: May be necessary to meet increased energy demands.
  • Sedation might be necessary for inconsolable infants to reduce cardiac demand due to continuous crying.