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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 13  |  Issue : 1  |  Page : 62-66

Pediatric heart failure among emergency room admissions in a Tertiary Health Centre in Southern Nigeria


1 Department of Paediatrics and Child Health, Niger Delta University, Wilberforce Island, Amassoma; Department of Paediatrics and Child Health, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State, Nigeria
2 Department of Paediatrics and Child Health, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State, Nigeria

Date of Web Publication13-Jan-2016

Correspondence Address:
Chika Onyinyechi Duru
Department of Paediatrics and Child Health, Niger Delta University, Wilberforce Island, Bayelsa State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-7969.165166

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  Abstract 

Introduction: Heart failure is a common pediatric emergency. This study was conducted to determine the prevalence and underlying causes of heart failure among children admitted to the Children's Emergency Ward of the Niger Delta University Teaching Hospital Okolobiri, Bayelsa State.
Materials and Methods: Over a 1-year period from January 1, 2014 to December 31, 2014; consecutive children presenting to the emergency ward with clinical features of heart failure were recruited. After stabilization and management, a proforma was opened for each patient containing details of the history, physical examination, underlying causes of the heart failure, method of treatment, and outcome.
Results: Of the 473 children seen over the study period, 79 of them presented with clinical features of heart failure, accounting for 16.7% of the total pediatric admissions with a male: female ratio of 1.4:1. Their ages ranged from 1½ months to 14 years (mean age 35.3 ± 34.9 months). The major underlying causes of heart failure were anemia (59.5%) and lower respiratory tract infections (21.5%). Severe malaria was the most common cause of anemia. Of the 79 cases, there were 17 deaths (case fatality rate of 21.5%), which accounted for over 50% of the total mortalities in the Children's Emergency room over the study period. Mortality from heart failure was significantly associated with increased severity of heart failure at presentation (P = 0.004; Fishers exact test).
Conclusion: Scaling up malaria prevention programs, strengthening immunization practices, prompt recognition and treatment of the underlying causes of heart failure would reduce morbidity and mortality from this easily preventable and treatable condition.

Keywords: Etiology, children, emergency room, heart failure, Nigeria, outcome, prevalence


How to cite this article:
Duru CO, Mesiobi-Anene N, Akinbami FO. Pediatric heart failure among emergency room admissions in a Tertiary Health Centre in Southern Nigeria. Nig J Cardiol 2016;13:62-6

How to cite this URL:
Duru CO, Mesiobi-Anene N, Akinbami FO. Pediatric heart failure among emergency room admissions in a Tertiary Health Centre in Southern Nigeria. Nig J Cardiol [serial online] 2016 [cited 2019 Dec 13];13:62-6. Available from: http://www.nigjcardiol.org/text.asp?2016/13/1/62/165166


  Introduction Top


Heart failure is a common pediatric emergency encountered in our hospital settings. It is a clinical syndrome characterized by the inability of the heart to meet the metabolic demands of the body and to dispose of pulmonary and systemic venous return or both.[1] It arises as a complication of most common childhood illnesses and can be fatal if not managed in a timely and appropriate manner. Heart failure can arise from underlying cardiac or noncardiac causes, which differ among various age groups and in different environmental settings. In Nigeria, anemia from infections such as malaria and lower respiratory tract infections (LRIs)[2],[3],[4],[5],[6],[7] have been reported as the most common causes of heart failure, unlike in developed countries where cardiomyopathies and structural heart diseases are more common.[8]

Heart failure is an important cause of mortality among pediatric emergency cases in our environment. An earlier study by the same authors [9] revealed that anemic heart failure was a major cause of mortality among emergency room admissions despite accounting for <10% of the emergency room admissions. The important contribution of heart failure to childhood morbidity and mortality makes it necessary, to determine further, the common underlying causes in our environment. Till date, no similar study has been carried out in Bayelsa State, thus, this study was conducted to determine the prevalence of heart failure among pediatric emergencies presenting to the Children's Emergency Ward (CHEW) of the Niger Delta University Teaching Hospital (NDUTH), Okolobiri, Bayelsa State, and also determine the common underlying causes.


  Materials and Methods Top


The study setting was the CHEW of the NDUTH, which is located in Okolobiri, a semi-urban community in Bayelsa State. During the 1-year study period (from January 1, 2014 to December 31, 2014) all children admitted to the CHEW of the NDUTH and who met the criteria for diagnosis of heart failure were prospectively studied. The criteria used to make a diagnosis of heart failure [10] in these children were the presence of tender hepatomegaly and any of the other 2 of the listed criteria below:

  • Significant tachycardia which is defined as a heart rate greater than the upper limit of normal for the age of the child; >160 bpm in infancy, >140 bpm at 2 years, >120 bpm at 4 years, and >100 bpm at 6 years and above. In patients with fever, an addition of 10 bpm was made for every degree rise in temperature above normal
  • Tachypnea which is defined as a resting respiratory rate above the normal for age; >60 bpm in those <2 months, >50 bpm in infants between 2 and 12 months, >40 bpm for children above 1-year of age
  • Cardiomegaly which is defined as a displaced apex beat with central trachea or a cardiothoracic ratio of >60% for the first 5 years of life and >50% for children >5 years of age.


On admission, the patients who met the above criteria were immediately identified using the triage system. A thorough physical examination was carried out and necessary interventions were given, which included administration of 100% oxygen through nasal prongs and antifailure medications, which included diuretics with or without angiotensin-converting enzymes, and digoxin where indicated. Those presenting with anemia were transfused with red blood cells. When the patient was stable with the aid of a proforma, the bio-data, relevant history, and physical findings were obtained to determine the underlying cause of the heart failure. The severity of the heart failure was assessed using the Modified Ross score.[11] Investigations such as the packed cell volume (PCV), blood for malaria parasite, and a full blood count were carried out on all patients. Chest radiograph was carried out in all patients who had clinical signs of an underlying cardiac or respiratory pathology. Patients with suspected congenital or acquired heart disease, in addition had an electrocardiogram and an echocardiography done to confirm the diagnosis. Blood cultures were carried out in all the patients with suspected sepsis.

Underlying causes, which were amenable to medical treatment such as malaria, septicemia, and LRIs were treated appropriately. Those with structural heart defects were continued on antifailure medications prior to referral abroad through the assistance of a Non-Governmental Organization based in Europe for free cardiac surgery. All the patients were managed accordingly till they were discharged, left against medical advice or died.

The patients were grouped into three age categories: 0–1 year, 1 to <5 years, and over 5 years; and the different causes of heart failure in each age group were analyzed. The data were entered into Microsoft Excel for Windows, which was also used to analyze continuous and categorical variables. The test of significance between proportions was assessed using the Fishers exact test, and a P < 0.05 was considered significant at a 95% confidence interval. Ethical approval was obtained from the Research and Ethics Committee of the NDUTH.


  Results Top


Age and sex distribution

A total of 473 children between the ages of 1 month and 16 years were admitted into the CHEW over the 1-year period (from January 1, 2014 to December 31, 2014). There were 276 males and 197 females accounting for a male: female ratio of 1.4:1.

Seventy-nine children are presented in heart failure at the CHEW, which accounted for 16.7% of the total pediatric emergency admissions. Their ages ranged from 1½ months to 168 months with a mean age of 35.3 ± 35.0 months. There were 46 males and 33 females with a male: female ratio of 1.4:1. The majority of the children; 42 (53.2%) who presented in heart failure were between the ages of 1 and 5 years [Table 1].
Table 1: Age and sex distribution of the 79 children presenting with heart failure in the CHEW

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Causes of heart failure

As shown in [Table 2], the major causes of heart failure in our study population was anemia, which was noted in 47 (59.5%) children followed by LRIs in 17 (21.5%) and sepsis in 9 (11.4%) children.
Table 2: Causes of heart failure in the 79 cases of clinically diagnosed heart failure according to the different age groups

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Of the 47 children with anemic heart failure, the highest cause of anemia was severe malaria in 26 (55.3%) children while the least cause was acute lymphoblastic leukemia in 1 (2.1%) child [Figure 1]. Most, 21 (80.8%) of the children with anemia secondary to severe malaria were between the ages of 1 and 5 years.
Figure 1: Pie chart showing the underlying causes of anemic heart failure

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The PCV of the 47 children with anemic heart failure ranged from 4% to 23% (mean 13.4%) while the PCV ranged from 25% to 37% (mean 29.5%) in those presenting with heart failure from causes other than anemia. The PCV of the 26 children who presented with anemia secondary to severe malaria ranged from 5% to 22% (mean 12.8%) while the PCV of those presenting with sickle cell anemia, sepsis, and LRI ranged from 4.0% to 9.0% (mean 7.0%), 9.0–23.0% (mean 15.5%), and 21.0–23.0% (range 22.0%), respectively. The child with anemia from acute lymphoblastic leukemia had a PCV of 9.0%.

Bronchopneumonia was the most common respiratory tract infection seen in 10 (58.8%) out of the 17 children with heart failure secondary to respiratory tract infections. This was followed by tuberculosis in 3 (17.6%), pertussis in 3 (17.6%), and lobar pneumonia in 1 (6.0%) children [Figure 2]. The child with lobar pneumonia was an 11-month-old male infant with severe measles.
Figure 2: The distribution of various types of lower respiratory tract infections causing heart failure in 17 children

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Of the 6 children who presented with heart failure secondary to structural heart defects, 5 (83.3%) were congenital heart defects (CHD) while 1 (16.7%) was an acquired defect (rheumatic heart disease [RHD]). All the 5 children with CHD were infants and all had ventricular septal defects (VSDs) either alone or in combination with other defects [Table 3].
Table 3: The distribution of structural heart diseases in the 6 children who presented in heart failure

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Based on the Modified Ross Scoring system, 7 children presented in severe heart failure while the remaining 72 presented in either mild or moderate heart failure. The underlying causes of heart failure in the 7 children presenting in severe heart failure were sepsis in 2, structural heart diseases in 2, anemia from severe malaria in 1, lobar pneumonia in 1, and tuberculosis in 1 child.

Outcome of cases of heart failure

During the 1-year study period, 53 (67.1%) of the children in heart failure were discharged home, 8 (10.1%) were discharged against medical advice, 1 (1.3%) was referred abroad for cardiac surgery, and 17 (21.5%) children died. For all the children who were discharged with or without medical consent, heart failure had resolved in all of them except the children with structural heart diseases who were discharged on antifailure medication and seen on outpatient basis in the cardiology clinic pending surgical intervention. Irrespective of the underlying cause of the heart failure, the total duration of admission of all the 79 children seen, ranged from 1 to 74 days with a mean of 8.3 ± 1.1 days. The average duration of hospitalization of the patients with anemic heart failure was 4.8 days while that of patients presenting with heart failure secondary to structural heart diseases was 28.5 days.

Mortality due to heart failure

Of the 79 children with heart failure, 17 died; accounting for a case fatality rate of 21.5%. Of the 33 deaths in the CHEW over the study period, heart failure accounted for 50.0% of the total pediatric emergency mortalities. Anemia was the most common cause of mortality accounting for death in 9 (52.9%) cases [Figure 3]. Of the 17 children who died, 5 presented with severe heart failure as compared to 2 out of the remaining 62 children who survived and this difference was statistically significant (P = 0.004. Fisher's exact test).
Figure 3: Pie chart showing causes of mortality

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  Discussion Top


Heart failure accounted for 16.7% of pediatric emergency admissions in our study. This is similar to the prevalence rates of 15.5% observed by Anah et al. in Calabar,[6] but higher than the rates of 5–10% reported from other parts of Nigeria.[2],[3],[4] This disparity could be attributed to the rural location of our hospital thus making it more assessable for the locales to use it as a primary and secondary health center such that emergencies are brought as the first port of call unlike the other centers, which may attend to mainly tertiary pediatric cases.

Causes of heart failure have been shown to differ among children of various age groups.[8] Children between the ages of 1 and 5 years accounted for over 50% of the affected children, which is similar to reports from other parts of Nigeria [3] and Africa.[12] This is in contrast to other reports from other parts of the country where infants were commonly seen.[2],[4] This difference may be related to the difference in patient selection as only children admitted into the CHEW were studied in our series unlike the studies, which involved all hospitalized children.

With mostly under-fives being reported in our study, it is not surprising that the leading cause of heart failure was anemic heart failure secondary to severe malaria. Previous studies by the same authors [9] have shown that anemic heart failure is a leading cause of morbidity and mortality among children admitted to the emergency wards in our environment. Anemia from malaria as the leading cause of heart failure in our series has also been similarly reported in Sagamu [4] and Calabar.[6] Children are more prone to severe malaria in malaria endemic regions such as ours because of their low immunity against infection by the malaria parasite, resistance of the antimalarial drugs and the rapid rate of clinical deterioration and development of complications in the presence of acute infections.[13] The anemia from severe malaria has been attributed to the acute destruction of parasitized red blood cells following infections with high parasite densities.[13]

LRIs and sepsis were other major causes of heart failure observed in our study. Infections have been reported by other authors in Nigeria [2],[3],[4],[5],[6],[7] and other parts of Africa [12] as important causes of heart failure. LRIs, particularly pneumonias have been found to be a leading cause of death among children under the age of 5 years in developing countries.[14] The coexistence of heart failure has been found to be a common association in children with pneumonia, which adversely affects prognosis.[15] The significant contribution of acute LRI's to childhood mortality and morbidity means that the strengthening of preventive immunization programs would help to reduce the incidence of this disease. The recent introduction of vaccines against Haemophilus influenza type B and Streptococcus pneumonia, which have been identified as leading bacteria pathogens in the etiology of childhood pneumonia into the Nigerian National Program on Immunization [16] would thus significantly reduce morbidity and mortality from LRIs and also prevent the associated complications.

CHD constituted <10% of the cases seen with heart failure with VSDs most commonly noted. Similar observations have been made by other authors.[2],[3],[4] The paucity of these patients presenting with CHD could be due to the various challenges facing the diagnosis and management of congenital heart diseases in our environment such as late presentation, ignorance about the disease, paucity of personnel and facilities for diagnosis and treatment, and the need for palliative and/or corrective surgery abroad.[17],[18] CHD are not given priority attention in developing countries by the government due to lack of political will and preoccupation of policy makers with infectious disease control.[17] Though various Non-Governmental Organizations [18] exist to support the cause, only a few children eventually benefit from such programs. RHD is the most common acquired heart disease in African children and young adults due to the prevailing issues of poverty, ignorance, and socioeconomic instability.[18],[19],[20] Despite this, only a few cases with heart failure with RHD have been reported in various Nigerian studies.[2],[4] Heart failure has been reported as a significant cause of morbidity and mortality from RHD.[19],[20],[21],[22] The inflammation and scarring of the heart valves with repeated rheumatic fever episodes lead to significant valvular regurgitation and/or stenosis mainly of the mitral and aortic valves leading to heart failure.[19] The low number of cases attributable to RHD may be due to either the presence of mild cases, which usually go undetected or ignorance on the part of health care workers on the presence and severity of the disease. It is also possible that the prevalence of RHD is on a decline as noted by Oyedeji et al. due to the prevalent use of antibiotics.[3]

Case fatality rate of pediatric heart failure in Nigeria and other parts of Africa has been reported to range from 7% to 33%.[3],[5],[6],[7],[12] With a case fatality rate of 21.5%, anemia was the main underlying cause in our study; an observation that has been reported by other authors.[7] The presence of heart failure in patients with anemia has been associated with poorer outcomes and increased mortality [9],[23] despite the fact that an urgent blood transfusion can be lifesaving.[24] The fact that increased severity of heart failure at presentation contributed significantly to mortality in this series means that early detection and treatment of the underlying causes would considerably reduce mortality from heart failure.


  Conclusion Top


Heart failure is a common pediatric emergency in our environment. It is a common complication observed in acutely ill under-fives presenting with anemia from malaria and other infections. Scaling up malaria prevention and treatment programs and strengthening the routine Immunization practices would help to reduce the incidence of anemia from malaria and infections. Prompt recognition and treatment of heart failure would lead to a drastic reduction in the morbidity and mortality from this easily preventable and treatable condition.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Park M. Paediatric Cardiology for Practitioners. 5th ed. New Delhi: Elsevier; 2007. p. 461-73.  Back to cited text no. 1
    
2.
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Oyedeji OA, Oluwayemi IO, Oyedeji AT, Okeniyi JA, Fadero FF. Heart failure in Nigerian children. Cardiology 2010;5:18-22.  Back to cited text no. 3
    
4.
Adekanmbi AF, Ogunlesi TA, Olowu AO, Fetuga MB. Current trends in the prevalence and aetiology of childhood congestive cardiac failure in Sagamu. J Trop Pediatr 2007;53:103-6.  Back to cited text no. 4
    
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Bondi F, Jayesimi F. Heart failure in an emergency room setting. Niger J Paediatr 1990;17:1-6.  Back to cited text no. 5
    
6.
Anah MU, Antia-Obong OE, Odigwe CO, Ansa VO. Heart failure among paediatric emergencies in Calabar South-Eastern Nigeria. Mary Slessor J Med 2004;4:58-62.  Back to cited text no. 6
    
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Olowu AO. Studies on heart failure in Sagamu. Niger J Paediatr 1993;20:29-34.  Back to cited text no. 7
    
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Hsu DT, Pearson GD. Heart failure in children: Part I: History, etiology, and pathophysiology. Circ Heart Fail 2009;2:63-70.  Back to cited text no. 8
    
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Duru C, Peterside O, Akinbami F. Pattern and outcome of admissions in the Paediatric emergency ward of the Niger Delta University Teaching Hospital, Bayelsa State, Nigeria. Niger J Paediatr 2013;40:232-7.  Back to cited text no. 9
    
10.
Omokhiodion SI. Childhood heart failure. In: Omokhiodion SI, Osinusi K, editors. Paediatric Cardiology and Respiratology. WACP Update Series. Lagos, Nigeria: West African College of Physicians; 1996. p. 72-82.  Back to cited text no. 10
    
11.
Ross RD, Bollinger RO, Pinsky WW. Grading the severity of congestive heart failure in infants. Pediatr Cardiol 1992;13:72-5.  Back to cited text no. 11
    
12.
Ogeng'o JA, Gatonga PM, Olabu BO, Nyamweya DK, Ong'era D. Pattern of congestive heart failure in a Kenyan paediatric population. Cardiovasc J Afr 2013;24:117-20.  Back to cited text no. 12
    
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Management of Severe Malaria: A practical handbook. 3rd ed. Geneva. World Health Organization 2012. Available from: http://www.who.int>iris>ISBN 9789241548526_eng-1.pdf. [Last assessed on 2015 Feb 12].  Back to cited text no. 13
    
14.
Bryce J, Boschi-Pinto C, Shibuya K, Black RE; WHO Child Health Epidemiology Reference Group. WHO estimates of the causes of death in children. Lancet 2005;365:1147-52.  Back to cited text no. 14
    
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Sadoh WE. Pneumonia complicated by congestive heart failure in Nigerian children. East Afr Med J 2012;89:322-6.  Back to cited text no. 15
    
16.
PAN Advisory Committee on Immunisation. Paediatric Association of Nigeria (PAN) recommended routine immunisation schedule for Nigerian children. Niger J Paediatr 2012;39:152-8.  Back to cited text no. 16
    
17.
Fidelia BT. Challenges in the management of congenital heart disease in developing countries. In: Rao PS, editor. Congenital Heart Disease – Selected Aspects. InTech; 2012. Available from: http://www.intechopen.com/books/congenital-heart-disease-selectedaspects/ challenges-in-the-management-of-congenital-heart-disease- in-developing-countries. [Last accessed on 2015 Jan 27].  Back to cited text no. 17
    
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Hewitson J, Zilla P. Children's heart diseases in sub-Saharan Africa: Challenging the burden of disease. SA Heart 2010;7:18-29.  Back to cited text no. 18
    
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Nkomo VT. Epidermiology of valvular heart diseases in Africa. SA Heart 2009;6:12-8.  Back to cited text no. 19
    
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Zühlke L, Mirabel M, Marijon E. Congenital heart disease and rheumatic heart disease in Africa: Recent advances and current priorities. Heart 2013;99:1554-61.  Back to cited text no. 20
    
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Mocumbi AO. Lack of focus on cardiovascular disease in sub-Saharan Africa. Cardiovasc Diagn Ther 2012;2:74-7.  Back to cited text no. 21
    
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Damasceno A, Cotter G, Dzudie A, Sliwa K, Mayosi BM. Heart failure in sub-Saharan Africa: Time for action. J Am Coll Cardiol 2007;50:1688-93.  Back to cited text no. 22
    
23.
Adegoke S, Ayansanwo A, Oluwayemi I, Okeniyi J. Determinants of mortality in Nigerian children with severe anaemia. S Afr Med J 2012;102:807-10.  Back to cited text no. 23
    
24.
Sadoh WE, Sadoh AE, Okposio M. Cardiovascular responses to blood transfusion in children with anemic heart failure. Niger J Clin Pract 2012;15:424-9.  Back to cited text no. 24
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