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The Criteria and degree of Heart failure in Indian children.
Authors
MUKTARALI KYZY BEGIMAI
SOZHA RAJA JANAKI KAAMESH
MEENATCHI SUNDARAM ARUNASRI
RAMESH AKSHAYA DHARANI
(1, Teacher , Department of clinical disciplines 2, International Medical Faculty , Osh State University , Kyrgyzstan
2,3,4, Student, 3rd Year , International Medical Faculty , Osh State University , Kyrgyzstan)
Abstract
A combination of congenital, acquired (including rheumatic), infectious, and cardiac conditions can result in paediatric heart failure (PHF), a significant source of morbidity and mortality in India. Bedside assessment, triage, and treatment decisions continue to rely heavily on clinical grading systems tailored for infants and children, most frequently the Modified Ross classification. Cardiomyopathies and myocarditis significantly contribute to heart failure presentations, and epidemiologic patterns in India show a high burden of congenital heart disease (CHD) and persisting pockets of rheumatic heart disease (RHD) both myocarditis and cardiomyopathies playing a significant role in the manifestation of heart failure. In addition to discussing Indian-specific concerns for diagnosis, staging, and resource-appropriate care, this article provides an overview of current clinical criteria and grading systems and shows typical etiologic proportions from pooled developing-world data.
Introduction
Compared to adult heart failure, heart failure in children presents differently depending on the etiology (congenital structural abnormalities, cardiomyopathies, myocarditis, RHD, severe anaemia/sepsis), age (infants vs. older children), and developmental stage (feeding, growth). Since many children appear in settings with limited resources, where echocardiography and advanced testing may be delayed, accurate clinical grading is crucial. National guidelines and standard treatment workflows that match clinical scoring (Modified Ross) with specific investigations and management actions are increasingly being followed in Indian practice. Standard treatment procedures and recent Indian advice documents place a strong emphasis on early detection, targeted examination (CBC, ECG, chest X-ray, echocardiography, when possible), and intervention referral pathways.
Methods
This article was developed through a narrative review of national guidelines related through paediatric heart failure in India. Relevant studies were identified from databases including PubMed, ScienceDirect, Google scholar. Guidelines and standard treatment workflows were sourced from the Indian council of Medical Research (ICMR,2024) and the Indian Academy of Paediatrics (IAP,2022).
Clinical Criteria and Grading Used In ChildrenThe most widely used paediatric grading tools are:
Modified Ross classification (infants and children) — adapted from Ross and subsequently modified to give a numeric/severity score. It grades heart failure from Class I (no HF) to Class IV (severe HF with rest symptoms).
NYHA-like functional assessment for older children and adolescents — describes limitations on activity and exertional symptoms analogous to adults but applied cautiously.
Results
Epidemiology And Causes
The major cause of paediatric heart failure, according to pooled data from systematic reviews and reports from developing countries, is congenital heart disease (about 50% of patients in pooled series), followed by cardiomyopathies/myocarditis (~19%) and acquired causes (RHD, infection, anaemia) (~18%). Studies conducted in Indian hospitals and registries support this trend, but there is geographical variation: RHD is still significant in many places, whereas CHD predominates in tertiary-centre cohorts and where screening and care are more readily available. These differences have major implications for prevention (RHD control), screening (RBSK screening programmes), and resource allocation for congenital cardiac services.
Ancillary Criteria and Investigations
Together with the clinical score, the following aid in staging and diagnosis:
Vital signs include hypoxia, tachycardia, and tachypnoea.
growth or failure, and infants' feeding habits.
Chest X-ray: pulmonary venous congestion/oedema, cardiomegaly.
ECG: irregular heartbeat, enlarged chambers.
Echocardiography: The gold standard for aetiology is echocardiography, which measures ventricular function (EF/FS), chamber dilatation, valve disease (RHD), and shunts.
Laboratory: tests include a metabolic screen if cardiomyopathy is suspected, CBC (check for anaemia and infection), and BNP/NT-proBNP (if available) as a severity measure.
Mild (Class II/low score): Close monitoring and outpatient management are possible; treat precipitating causes (anaemia, infection), optimise nutrition, and take diuretics if volume overload occurs. Echocardiography is advised within a brief window.
Moderate (Class III/moderate score): Needs hospitalisation for definitive imaging, careful feeding support, and diuresis; if a congenital lesion is causing overload, evaluate for immediate intervention (Cath or surgery).
Severe (Class IV/high score): immediate referral to paediatric cardiology or cardiac surgery, ventilatory support, ICU care, and inotropes as necessary. Outcomes depend strongly on aetiology (e.g., global systolic dysfunction vs. treatable shunt lesion)
Discussion: Indian practice Implications
Early detection (school/primary-care screening, RBSK) reduces late presentation and emergency surgeries.
Resource-stratified pathways (ICMR STW and IAP STG) recommend bedside scoring + minimal investigations at first contact and echo/referral pathways when available.
Preventable causes: RHD prevention through sore-throat management and rheumatic fever prophylaxis remains critical in some regions
Limitations And Research Gaps
High-quality community incidence/prevalence data for paediatric HF in India are limited; most information comes from tertiary centres or small surveys. National registries and population-based echocardiographic screening studies would clarify burden and inform planning
Conclusion
Paediatric heart failure in India remains a multifactorial condition influenced by both congenital and acquired causes, with congenital heart diseases leading the aetiology and rheumatic heart diseases still contributing significantly in many regions. Early recognition through structured clinical criteria such as the Modified Ross classification allows clinicians to assess severity accurately and initiate timely management, even in resource –limited settings. Implementation of standardized workflows, like those developed by Indian Council of Medical Research (ICMR)and Indian Academy of paediatrics (IAP), has improved uniformly in diagnosis and treatment across different care levels. However, there remains an urgent need for large –scale epidemiologic studies, better screening programs and increased access to paediatric cardiac services. Strengthening community-level awareness, preventive measures for rheumatic fever and early referral pathways will be key to reducing the morbidity and mortality associated with paediatric heart failure in India.
References
“The value of modified Ross score in the evaluation of children with heart failure”— PMC article, discusses using Modified Ross in paediatric patients, and its correlation with outcomes. Link: https://pmc.ncbi.nlm.nih.gov/articles/PMC9899196/
“Heart Failure in Children” — Circulation / AHA (Modified Ross classification description)— Includes the description of the Modified Ross classification and how it’s applied in children. Link (PDF): https://www.ahajournals.org/doi/pdf/10.1161/circheartfailure.108.820217 Also, HTML version: https://www.ahajournals.org/doi/10.1161/circheartfailure.108.820217
ICMR Standard Treatment Workflow: Paediatric Heart Failure— National Indian guideline / workflow for paediatric heart failure, useful for Indian context. Link (PDF): https://www.icmr.gov.in/icmrobject/uploads/STWs/1726651147_3_pediatric_heart_failure.pdf
“Paediatric Heart Failure: A Practical Guide to Diagnosis and Management”— Review article summarizing criteria, classification, diagnostic approach, including Modified Ross. Link: https://www.sciencedirect.com/science/article/pii/S1875957217300505
“The Ross Classification for Heart Failure in Children After 25 Years”— Review / revision history of the Ross classification, age stratification, and critiques.Link: https://pubmed.ncbi.nlm.nih.gov/22476605/And full version via ResearchGate: https://www.researchgate.net/publication/223958463_The_Ross_Classification_for_Heart_Failure_in_Children_After_25_Years_A_Review_and_an_Age-Stratified_Revision
6.“Modified Ross score and echocardiographic score in children with heart failure: a subgroup analysis”—Compares the clinical (Modified Ross) and echo scores and their correlations among children with heart failure.Link: https://paediatricaindonesiana.org/index.php/paediatrica-indonesiana/article/view/3381. Also, summaryonResearchGate:https://www.researchgate.net/publication/381965898_Modified_Ross_score_and_echocardiographic_score_in_children_with_heart_failure_a_subgroup_analysis
IAP / Indian paediatric STW / workflows— Indian Council of Medical Research’s list of Standard Treatment Workflows (STWs) including paediatric heart failure workflows. Link: https://www.icmr.gov.in/standard-treatment-workflows-stws Also the STW cover document/volume reference: https://www.icmr.gov.in/icmrobject/uploads/STWs/1733131852_stw_vol_4_2024.pdf
