Hugh D.Allen, MD, Deputy Editor, Pediatrics in Review
Dr. Price, an internationally recognized expert in pediatric heart failure and transplant,
presents an exceptional article on heart failure in children in the February issue of Pediatrics in Review. The updated concepts that he details
are important to the primary care provider, to cardiologists who care for children,
and to trainees. I would implore your careful reading of this paper. I will offer
some commentary, rather than trying to repeat his carefully done text.
For the primary care provider:
We cannot treat what we do not see. It is incumbent upon the primary care physician
to recognize that the wheezing, distressed infant with tachypnea and tachycardia has
more than bronchiolitis.1 This can be especially difficult in a busy clinic or emergency room during an RSV
epidemic but is rather easily resolved by obtaining a thoracic roentgenogram for the
infant with respiratory distress who has presumed RSV bronchiolitis and who is getting
clinically worse (See Fig 1 in Dr. Price’s article).
If the infant with heart failure is not recognized, he/she cannot receive care and
will likely die. The implication is to “overreact” and obtain a radiographic study
rather than to trust your instincts, then to refer on an emergent basis.
For the cardiologist:
Treatment of heart failure in children is an evolving issue. It is incumbent upon
clinicians to stay abreast of this literature. As of now, the life-saving use of angiotensin
inhibitors has changed the landscape, often allowing heart failure patients to come
off transplant lists. As a side note, it is interesting to recall that these medications
derived from observations of the effects of banana plantation workers being bitten
by a Brazilian pit viper. This important observation led to important research on
the renin-angiotensin cycle in Sir John Vane’s laboratory, and 25 years later we have
these miracle drugs.
Advances in transplant therapy, ventricular assist devices, destination strategies,
and pharmacology have further improved patient care and will continue to do so. With
the ongoing shortage of donor hearts, it is incumbent upon clinicians to understand
and enhance these therapies as far as possible.
For the trainee:
In 1968, Dr. Robert Good performed the world’s first bone marrow transplant at the
University of Minnesota. I was the resident on the case and can attest to his foresight
and brilliance. He always reminded us to pay attention to “experiments in nature.”
A horrible disease – Duchenne muscular dystrophy – offers such insights regarding
heart failure in children. A great deal of information and strategies have emerged
from this population and will continue to do so. This offers a fertile arena, among
many others (including the emerging young adult population with new morbidities),
for young investigators to pursue studies on causes, natural and unnatural histories,
genetic implications, and therapeutic options. This is where the future will be brightest
for future generations. Consider this a gauntlet thrown down to you. I envy your opportunities
to change the future of this population and wish that I could be part of it. Godspeed!
Franklin WH, Dietrich AM, Hickey RW, Brookens MA. Anomalous left coronary artery masquerading
as infantile bronchiolitis. Pediatric Emergency Care. 1992 Dec;8(6). 338-41.