Children and Heart Disease: An under recognized problem

Some countries, such as the UK, have taking action by banning advertising of high fat, salt and sugar products during or around programs made for children, or that are likely to appeal to children, due to the link between food advertising and childhood obesity.
Children and Heart Disease: An under recognized problem

Children are our asset, and their health and wellbeing is our responsibility. It goes a long way in the development and progress of a family, our community and nation. 

Unfortunately heart diseases in children and adolescents are often not recognized in time and due attention is not given to these in our milieu. It is a big burden on our society. Most of them if picked in time and very early can be corrected and can have a normal life in adulthood.   

These diseases come under 2 Categories: 

1. Birth Defects (Congenital Heart Diseases)

2. Acquired Heart Diseases 

Birth Defects:

Congenital heart disease (CHD) is the type of heart disease that a baby is born with. In reality, it is a defect, or abnormality of the heart or blood vessels near the heart, and not a disease, so many people use the term "congenital heart defect". The majority of children born today with CHD will survive and with proper treatment be able to lead a normal or near-normal life. Some kinds of CHD are mild and may not be diagnosed in infancy. Other types of CHD are severe and will be diagnosed soon after birth. Some will also be diagnosed before birth in the prenatal screening. 

Examples of CHDs are:

One in every 125 babies born has congenital heart defects, which incidentally, is also the most common birth defect. The eight most common defects account for 80 percent of all congenital heart diseases, while the remaining 20 percent consist of many independently infrequent conditions, or combinations of several defects. 

Ventricular Septal Defect (VSD) is generally considered to be the most common type, accounting for about one-third of all congenital heart defects. It is estimated that 125,000 children are born every year with congenital heart disease. Many of these children will have curable conditions and with good long-term prognosis. The common defects encountered in the population are;

1. Ventricular septal defect,  (a hole between the lower 2 chambers of the heart).

2. Atrial septal defect, (a hole between the upper 2 chambers of the heart).

3. Coarctation of the aorta (the main artery leaving the heart [aorta] is constricted)

4. Transposition of the great arteries (the 2 large arteries leaving the right and left sides of the heartare switched).

5. Tetralogy of Fallot (a complex condition involving several structural defects).

Acquired

Broadly the defects are divided into 2 groups depending upon whether the baby is blue or not blue. Blue baby has its lips, nails and tongue etc bluish in color instead of pink.

Babies with birth defects who are not blue come under the category of Acyanotic Heart Disease and those who are blue come under the category of Cyanotic heart disease.

Acyanotic heart disease is when the child is not blue. Common conditions include atrial septal defect, ventricular septal defect, patent ductus arteriosus, and common atrioventricular canal defect. These are conditions associated with "holes" in the heart and increased blood flow to the lungs. The infants present with symptoms and signs of congestive cardiac failure such as breathlessness, failure to thrive, poor feeding, excessive sweating and multiple admissions for lung infections. Coarctation of aorta is a condition wherein there is a tight narrowing in the aorta (the main blood vessel supplying oxygenated blood) restricting blood flow to the lower part of the body. Newborns (neonates) may present with this condition and require emergency surgery.

Most of the above-mentioned conditions are straightforward surgical or amenable to corrections without surgery by non-surgical procedures called interventional procedures. 

The misfortune in our setting is that in our set up is that due to various reasons, children are brought late to experts. Some succumb to complications like heart failure or pneumonia. Others present too late as the lung pressure would have increased, pre-empting successful closure of the heart defects. There are various reasons for this: late diagnosis and referral, lack of funding, fear of surgery, ignorance etc.

Cyanotic heart disease is when the child is blue. It includes tetralogy of Fallot, transposition of great arteries, tricuspid atresia, total anomalous pulmonary venous connection (TAPVC) and truncus arteriosus. Many of the children suffering from cyanotic heart disease have to be dealt with as soon as they are born, else they will not survive.

They require timely recognition and transfer to specialized cardiothoracic units geared for neonatal work. Most conditions are complex. Tetralogy of Fallot is the commonest cyanotic condition. The child has a defect in the heart and variable degree of block in the blood supply to the lungs. They require to be monitored by the pediatric cardiologist and either a shunt as a preliminary operation or a total intra cardiac repair of the defect is required. Transposition of great arteries a condition in which the main arteries Aorta and Pulmonary arteries are arising from the wrong ventricles. This can be corrected by an arterial switch with excellent long-term results. The earlier they present, the better the results. They should ideally be operated in the first 3 weeks of life.

Babies with TAPVC (Total anomalous pulmonary venous connection) can obstruct at any time and collapse. They should be operated upon without delay. Many of these children will have curative surgery. Some will require multiple interventions. All children operated should be under the follow-up of a specialized pediatric cardiologist. 

The facilities for these procedures both diagnostic and therapeutic need very specialized team and set up. It is available in selected centers in metropolitan cities. It is gratifying to note that these specialized facilities are being extended to smaller cities at a rapid pace.

Acquired Heart Disease in Children:

This type of heart disease is not present at birth. The predominant two major types of acquired heart disease in children are rheumatic heart disease and Kawasaki disease.

Rheumatic heart disease

 Rheumatic heart disease (RHD) is the most common acquired heart disease in the developing countries of the world which includes India. Up to 1% of school children according to several surveys have this problem

It is a condition where the heart muscle and heart valves are damaged due to rheumatic fever. Rheumatic fever is caused by streptococcal bacteria, and usually begins as a consequence of sore throat in children that was undiagnosed or was not treated or under-treated.

The global burden of disease caused by rheumatic fever and RHD currently falls disproportionately on children and young adults living in low-income countries and is responsible for about 233,000 deaths annually .At least 15.6 million people are estimated to be currently affected by RHD with a significant number of them requiring repeated hospitalization and, often unaffordable, heart surgery in the

next five to 20 years. The worst affected areas are sub-Saharan Africa, south-central Asia, the Pacific and indigenous populations of Australia and New Zealand.

Fortunately the incidence of rheumatic fever and RHD is coming down due to improving socio-economic conditions and relatively less overcrowding.

Primary prevention of acute rheumatic fever (the prevention of initial attack) is achieved by treatment of acute throat infections caused by group A streptococcus. This is achieved by up to 10 days of an oral antibiotic (usually penicillin) or a single intramuscular penicillin injection. Rheumatic fever vaccine has been a big hope which is still unfulfilled. One of the reason being that the countries which have the expertise and the finances to do research on this have it as a low priority because this problem has significantly diminished there because of better living standards.

People who have had a previous attack of rheumatic fever are at high risk for a recurrent attack, which worsens the damage to the heart. Prevention of recurrent attacks of acute rheumatic fever is known as secondary prevention. This involves regular administration of antibiotics especially long acting penicillin, and has to be continued for many years. Secondary prevention programs are currently thought to be more cost-effective for prevention of RHD than primary prevention and may be the only feasible option for low- to middle-income countries in addition to poverty alleviation efforts.

  Surgery is often required to repair or replace heart valves in patients with severely damaged valves, the cost of which is very high and a drain on the limited health resources of poor countries like ours.

Kawasaki disease

Kawasaki disease is characterized by fever, rash, swollen hands and feet, bloodshot eyes, swollen lymph nodes, a strawberry appearance to the tongue, and an acute inflammation of the blood vessels, especially the coronary arteries.

Its cause is unknown but may be some kind of infectious agent. It occurs in young children – 80% or more are less than 5 years old, and occurs more in boys than in girls.

Kawasaki disease is most common in Japan, but has been seen in virtually every country in the world and is the leading cause of acquired heart disease among children in developed countries. It has been reported from several parts of India including Jammu and Kashmir. In some children, especially those who are undiagnosed or untreated or not treated soon enough, serious heart damage can occur.

Childhood overweight/obesity can lead to heart disease in later life:

Risk factors for Cardio vascular disease are determined to a great extent by behavior learned in childhood and continued in to adulthood – such as dietary habits. Childhood and adolescent overweight is one of the most important current public health concerns in developed economies. 

 The problem is global and is steadily affecting many low- and middle-income countries, particularly in urban settings. Overweight and obese children and adolescents are likely to develop a number of precursors for CVD, such as type-2 diabetes, hypertension, dyslipidemia and the metabolic syndrome.

Childhood overweight /obesity can lead to heart disease risk in later life.Cardiovascular disease 

There is strong evidence that an epidemic of childhood obesity has led to a significant increase in the prevalence of cardiovascular risk factors, which, if left unchecked, is likely to lead to an epidemic of premature cardiovascular disease. Heart attacks and related problems are becoming a major problem in our country all over and childhood obesity problem can further compound it.

Worldwide, one in 10 school-aged children is estimated to be overweight. Globally, in 2010 the number of overweight children under the age of five is estimated to be over 42 million. Close to 35 million of these are living in developing countries. Childhood obesity is already an epidemic in some areas and on the rise in others. 

Societal changes associated with economic growth, modernization, globalization, as well as changes in nutrition habits across the world, are driving the obesity epidemic. Many factors are fueling the obesity epidemic in children, such as increased consumption of energy-dense, high-calorie foods and drinks, and decreased physical activity. Schools have a very important role in preventing obesity by providing more nutritious food and by providing greater opportunities for physical activity, and counseling against becoming obese.

 Some countries, such as the UK, have taking action by banning advertising of high fat, salt and sugar products during or around programs made for children, or that are likely to appeal to children, due to the link between food advertising and childhood obesity. 

We are at crossroads with both under nutrition and over nutrition being seen in our young population. Health education and provision of nutritious meals at school is being practiced in some of our states. The government of India initiated the National Program of Nutritional Support to Primary Education (NP-NSPE) on 15 August 1995. The objective of the scheme is to help improve the effectiveness of primary education by improving the nutritional status of primary school children.

It is very important for the community and various relevant agencies to realize that children are our biggest asset and we need to do our best to keep them healthy. This should start from early childhood to make our nation a Healthy Nation.  

Dr Upendra Kaul  is Executive Director and Dean Batra Hospital and medical Research Centre , New Delhi 

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