Dr. Gregory Weiss offers perspective on the unique set of challenges that accompanies the treatment of children with cardiovascular conditions as opposed to treating adult patients.
For the most part, cardiovascular disease is seen as a problem for adults. It is true that aside from managing congenital heart defects the vast majority of cardiovascular care is rendered to adults. Some trends over the last few decades have been shifting the focus more and more to young people and even children and they are not good trends. Needless to say, pediatric cardiology has been a valuable subspecialty for quite some time. Increasing rates of childhood obesity, diabetes, and high cholesterol levels along with higher rates of congenital heart disease survival means more and more kids will be found in cardiologist’s offices and treatment rooms.
Taking care of children presents clinicians with several unique challenges and often comes with frustration. The unique issues treating children present can be divided into two basic categories: Age-related and parent-related compliance with examinations and treatment and disease related differences from adults.
Let’s face it, anyone with children of their own knows that they can be difficult to negotiate with. Starting from infancy up to about six years of age, simply cooperating with an exam can be difficult for children. Something as simple as taking a blood pressure can take a long time and yield less than accurate measurements due to squirming, refusing, or crying. In addition to lack of cooperation on the part of the child, parents can present a challenge as well.
The best-case scenario when a child needs to see a cardiologist is that the child and the parents are apprehensive and maybe even scared. From there you may have to interview a very distraught parent or parents and examine a hysterical patient. This continuum is difficult to predict and even harder to plan for. They wouldn’t be coming to you unless they were referred for a problem so expect to encounter a lot of questions. It is imperative that you provide a safe and comfortable, non-threatening environment.
We would like to think that all parents are strongly invested in the care and wellbeing of their children but unfortunately, some parents may not be good historians or, worse, they could be contributing to the problem. In some cases, parents may be defensive and evasive owing to guilt over their child being sick or in rare cases because they have neglected them. Part of our job as clinicians is to get an idea of what the family dynamic is in an effort to communicate well with all involved. It is imperative with children that that trust be built between the clinician the child and the child’s parents.
Pediatric cardiovascular problems present challenges of their own. Hypertension has been increasing in children possibly owing to obesity. When screening children for hypertension it is important to measure blood pressure when they are in a quiet state and it is vital to use the right sized cuff. Taking repeat measures on different occasions is important with adolescents since only 1 in 100 elevated first readings will go on to be hypertensive on a second screening. Kids that fit into this 1% are often taller, heavier, and have greater bone density than those with lower readings. When hypertension is diagnosed clinicians should be vigilant for other cardiovascular risk factors. Often high blood pressure is accompanied by insulin resistance and hyperlipidemia, a condition similar to the metabolic syndrome in adults but called syndrome X in children.
Pediatric hyperlipidemia has also become a big problem. The average American diet contains more than 30% fat which is over 10% more than the American Heart Association recommends. Talking to parents about modifiable risk factors is the best way to prevent serious cardiovascular disease in children. Talk to kids and parents about not smoking, about making exercise a big part of their daily lives and provide them with information on diet and weight management. You may find that parents have no idea what a heart healthy lifestyle entails. The cardiologist may be the first person who ever talked to them about diet.
Although uncommon, children will present with chest pain to their primary care providers and possibly the emergency department. While true cardiac causes are rare it is important to screen these kids for left ventricular outflow obstruction, hypertrophic cardiomyopathy, myocarditis, pericarditis, Kawasaki disease, and possibly anomalous origin or course of the coronary arteries. If a cardiac workup is negative GI disorders may mimic cardiac chest pain. In the active child or adolescent, chest pain is often of musculoskeletal origin.
Finally, children who present with arrhythmias, palpitations, or syncope should be examined and at a minimum, have an electrocardiogram. There should be a low threshold for obtaining a Holter monitor study and an echocardiogram if the symptoms are severe or persistent. Often times it is normal for a child to experience syncope once such as a fainting spell before adulthood, but multiple or prolonged episodes should lead to an in-depth investigation.
Although the majority of children are lucky enough to be healthy and happy kids it is important for us to be vigilant for those with existing cardiovascular disease or risk factors for it. While it can be frustrating examining and treating children using patience and respect can go a long way. Primary care providers should know what to look out for and not be afraid to refer children and adolescents to a specialist if warranted. Prevention is the best way to reduce mortality and morbidity from cardiovascular disease so counseling and treating kids is a great way to get the ball rolling.