Factors Predicting Heart Failure in Children Admitted to a Pediatric Emergency Ward in a Developing Country

To determine the clinical characteristics of children with acute heart failure syndrome in the emergency ward of River state university teaching hospital, Nigeria and identify factors associated with poor outcomes.

Methods

This was an 18month retrospective review of the acute heart failure register. Poor outcome measures were defined as the persistence of heart failure after 4 days on admission or death.

Results

Ninety-two (4.1%) of 2,244 children admitted were in heart failure, Non-cardiac disorders [bronchopneumonia 32(36%), sepsis 21(24%), severe malaria 10(11%), sickle cell anaemia 8(9%) and tuberculosis 3(3%)] contributed to 74(83%) while congenital heart disease(CHD) was 15(17%). Seventy-four (83%) were discharged, 10(11%) died and 4(5%) left against medical advice. The median time to resolution of heart failure was significantly 24 hours longer for malnourished children than those with normal-nutritional status, 72Vs48hrs, log rank:0.001. Those with modified Ross score of >7 and sepsis were more likely to die, OR,8.8(95% CI,1.2 to 72.5,p = 0.02) and 3.9(95% CI,1.01 to 15.2;p =0.04). Age <2yrs(OR,3.1,CI,1.2 to 8.5,p = 0.02), and CHD (OR 3.6,95% CI,1.1 to 12,P=0.02) were associated with a higher likelihood of having a poor outcome. Each unit increase in weight for age Z score of 1, decreased the odds of having a poor outcome, OR,0.77 (95% CI,0.63 to 0.95)p=0.016.

Conclusion

Heart failure in our setting is predominantly caused by non-cardiac disorders. Modified Ross score of >7 and sepsis are risk factors for mortality in children with heart failure. Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0

Child; Heart Failure; Pediatric Emergency; Mortality and Morbidity; Critical Care Outcomes; Emergency Service, Hospital

Variable		All patients (n=89) (%)
Age months (Median, 25^th,75^th percentile)		11 ( 5, 38)
1month to ≥ 5 yrs	72 (81)
>5 to 10 yrs	11(12)
>10 yrs	6 (7)
Gender
Female	44 (49)
Male	45 (51)
Residence
Urban	72 (81)
Rural	17 (19)
Who child resides with
Both parents	80(90)
Single parent	5(6)
other	4(4)
Social class of parents
Upper class (1 to 1.7 )	9(10)
Middle class (1.8 to 3.3)	52(58)
Lower class (3.4 to 5)	28(32)
Prior treatment
Yes to medications	67(75)
No to medications	22(25)
Prior Medications (N= 67)
Prescribed	28(42)
Over-the-counter	29(43)
Herbal	10((15)

Variable	All patients (n=89) (%)
Nutritional status Z-score (median, IQR)	-2.1 (-3.7, -0.5)
>2SD (Overweight)	4(4)
2 to -2SD (Normal)	39(44)
<-2 to -3SD ( Moderate Malnutrition)	14(16)
<-3SD (Severe Malnutrition)	32(36)
Hemoglobin in g/dl (median, IQR)	8.6 (6.3, 11)
Hb <8g/dl	41(46)
Hb >8g/dl	48(54)
Dysmorphic features
Yes	10(11)
No	79(89)
Modified Ross score
3 to <7 (Mild HF)	20(23)
7 to <11 (Mod HF)	67(75)
11 to 12 (severe HF)	2(2)
Cause of Heart Failure
Bronchopneumonia	32(36)
Sepsis	21(24)
Congenital heart defect	15(17)
Severe Malaria	10(11)
Sickle cell	8(9)
Tuberculosis	3(3)
Treatment received
Blood transfusion	41(46)
Furosemide	64 (72)
Captopril	15(17)
Spironolactone	15(17)
Digoxin	15(17)

Outcome	N (%)	Median in hours (1QR)
Heart failure resolved	74(83)	60 (60; 108)
Death	10(11)	180 (60; 348)
Discharged against medical advice	4(5)	156 (48;216)
Referred	1(1)	2 (2)

Variable	Poor Outcome (n= 36)(%)	Odds ratio	95% confidence interval		P
Variable	Poor Outcome (n= 36)(%)	Odds ratio	Lower	Upper	P
Residence
Urban	32(44)	2.6	0.7	8.8	0.1
Rural	4(24)
Who child lives with
Both parents	35(45)	0.1	0.01	1.3	0.06
Others	1(11)
Age
<2yrs	29(49)	3.1	1.2	8.5	0.02
>2yrs	7(23)
Gender
Female	20(45)	0.6	0.3	1.6	0.34
Male	16(35)
Referred
Yes	18(50)	1.9	0.8	4.6	0.13
No	18(34)
Social class
Upper	8(38)	1.1	0.4	3.2	0.8
Lower	28(41)
Family size
>4 children	7(35)	1.3	0.5	3.7	0.6
<4 children	29(42)
Nutritional status
Severe Malnutrition	16(50)	1.9	0.8	4.5	0.17
No severe Malnutrition	20(35)
Z-score Weight/age	-	0.77	0.63	0.95	0.016
Dysmorphia
Yes	8(80)	7.2	1.5	36	0.009
No	28(35)
Modified Ross >7
Yes	22(61)	1.5	0.6	3.5	0.3
No	141(38)
Prior treatment
Yes	7(32)	1.6	0.5	4.5	0.3
No	29(43)
Herbs
Yes	5(50)	1.5	0.4	5.6	0.3
No	31(39)
PCV <24
Yes	14(34)	0.6	0.3	1.4	0.2
No	22(46)
Sepsis
Yes	9(42)	1.1	0.4	3.0	0.06
No	27(40)
Bronchopneumonia
Yes	10(31)	0.5	0.2	1.3	0.1
No	26(46)
Coronary heart disease
Yes	10(67)	3.6	1.1	12	0.02
No	26(35)
Malaria
Yes	2(20)	0.3	0.6	1.6	0.1
No	34(43)
Blood transfusion
Yes	15(36.5)	0.7	0.3	1.7	0.5
No	21(43)

		B	SE	Wald	df	Sigma	Exp(B)	95% CI for EXP(B)
		B	SE	Wald	df	Sigma	Exp(B)	Lower	Upper
Step 1^a	Z-scoreWA	-.202	.112	3.261	1	.071	.817	.656	1.017
	<2yr(1)	.837	.535	2.449	1	.118	2.310	.810	6.594
	Rossgt7(1)	.310	.462	.450	1	.502	1.364	.551	3.375
	Constant	-1.585	.525	9.108	1	.003	.205

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