Published in Panorama
Acquired Heart Disease in Children
Contrary to popular belief, there is a fair proportion of children falling prey to Acquired Heart Disease (AHD), says Dr.Prem Sekar, Consultant Paediatric Cardiologist, Apollo Hospitals, Chennai, who was recently in Dubai. Every year, at least 50,000 children born with a normal heart develop heart problems after birth. Some of these disorders include myocarditis, pericarditis, rheumatic heart disease (RHD) which are caused by infection such as rheumatic fever, cardiomyopathy from certain viral infections or due to Kawasaki's disease, an inflammatory disease whose cause is unknown.
According to the American Heart Association, more than 1,800 cases of Kawasaki disease are diagnosed in the U.S. alone, each year. The illness occurs before the age of 5 and rarely after 8 and for some unknown reason, it is believed to affect boys more than girls. The disease gets its name from the fact that it was first found in Japan, though it is prevalent worldwide.
Describing the disease Dr.Sekar reveals, “It’s cause is not known but it is characterized by widespread inflammation of the blood vessels and causes irritation of many bodily tissues. Besides high fever and irritability, common symptoms include redness of lips, eyes, tongue, hands and feet, rashes and arthritis in the small joints. Though in most cases there may be no lasting damage, it can be especially dangerous when it affects infants. Often in the early stages of the disease, one symptom may appear as another disappears and though the child may appear to be making a recovery, he/she may actually worsen. Since the major threat of Kawasaki Disease is damage to the heart and blood vessels, it is important to diagnose and treat it at the earliest. Heart muscle, lining and valves may be damaged or weakened and there is danger of the inflammation progressing to the coronary arteries, though any other arteries may also be affected. When this happens there may be clot formations, aneurysms, leakage of valves, or accumulation of fluid around the heart. In rare instances, complications of Kawasaki disease can lead to heart attack in a child, which can be fatal.”
Explaining the other conditions leading to AHD, Dr.Sekar says, “Children born with a normal heart can acquire a heart problem after an infection which can affect the heart muscles, making it flabby and hence unable to pump blood well. This condition is called dilated cardiomyopathy.”
Children may become victims of Pericarditis, a condition where there is more than the normal level of fluid between the pericardium, a sack surrounding the heart and the heart itself. This extra fluid is usually the result of a viral infection or by a form of arthritis. The child suffering from pericarditis may complain of chest pain, shortness of breath and may exhibit symptoms of fever, fatigue, loss of appetite and irritability. Since these symptoms may mimic those of other systemic problems, medical advice is necessary to make the right diagnosis, says Dr.Sekar.
Elaborating on other conditions leading to AHD, Dr.Sekar explains, “The most commonly heard about AHD is Rheumatic Heart Disease (RHD) which is quite prevalent in tropical countries. It is very commonly seen in the lower socio-economic groups rather than in the affluent populations. This is because their conditions of living and hygiene, are low as a consequence of which they are more prone to infections of all kinds. Rheumatic fever is a common inflammatory disease that can occur after streptococcal infections of the respiratory tract. Sore throat may be the starting point . The bacteria targets the valves in the heart and damages them. On rare occasions, it can lead to congestive heart failure.”
Is it then true that tonsillitis can lead to RHD? Dr.Sekar assures, “Though you do have sore throat in tonsillitis, not all cases of tonsillitis would result in RHD. But there is some kind of genetic susceptibility.”
Is there some kind of age range within which children may develop Rheumatic Fever and hence AHD? Dr.Sekar clarifies, “Rheumatic fever usually affects the 5 to 15 year olds. The dilated cardio myopathy can happen any time following something as innocuous as a simple cold.
Not all children with rheumatic fever, need have cardiac involvement, emphasis Dr. Sekar. So how does one even suspect a heart condition following infection? The symptoms associated with the various diseases, provide the starting point for diagnosis according to Dr.Sekar. “In the case of rheumatic fever, the fever is accompanied by joint pains which are typical in that they involve the big joints and also usually one at a time. Moreover, by the time one joint gets better, pains begin in another joint. The condition is called flitting and fleeting arthritis, affecting mainly the knee, ankle and elbow joints. Very rarely, the small joints of the hand are involved. So once we ensure clinically that the condition is rheumatic fever, we do an echo cardiography to see if the heart is involved.”
Explaining certain precautionary measures Dr.Sekar reveals, “After doing an echo cardiography, whether or not the heart is involved, we put these children on penicillin prophylaxis, that is, penicillin injections which are given to them every 21 days. Alternatively, they may take penicillin tablets but these have to be taken twice everyday. This is mainly because penicillin is the most effective drug against the streptococcus bacteria causing the rheumatic fever. Ideally, these children are on a life long penicillin prophylaxis. However, let me emphasize that this will not cure the heart if it is already affected, but it will prevent other attacks of rheumatic fever which can happen. If it happens again, it is likely to be more severe affect the heart if it had not already done during the earlier bout. In instances where the child is known to be allergic to penicillin, he/she may be given other oral medicines though these are not as effective as penicillin.”
It is very important to suspect and diagnose the heart problems early so that remedial measures may be taken before the heart and lung are damaged so that the child may lead a normal life. “It is very unfortunate”, rues Dr.Sekar, “that even to this day many such children with heart defects go undiagnosed or are found to have a heart problem so late that permanent damage to the lungs and heart have already occurred resulting in a severely shortened lifespan. To facilitate early detection, it is essential for the parents or relatives to be able to recognize some of the telltale signs and symptoms, which may point to a cardiac problem in their child.”
If for instance, a child has suffered recent cold and exhibits tired feeling even after 2-3 weeks, unable to shake off the cold, unable to climb stairs without feeling fatigued and breathless, it should be immediately checked out. An echocardiography should be taken which could reveal an enlarged heart, not pumping well. This usually tends to become okay on its own, but sometimes it can very rapidly progress and lead to a cardiac transplant kind of situation, cautions Dr.Sekar.
Dizziness, fainting, breathlessness and palpitations are other symptoms to look out for, says Dr.Sekar.
Are AHD treatable? “Great strides have been made in pediatric cardiology and there is no such condition now which is totally untreatable. You may not be able to cure the condition 100%, but you can palliate it.”
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