What are the Cardiovascular diseases seen in children?
The majority of children who suffer from heart disease have a congenital heart defect. These are structural heart defects a child is born with. Congenital heart defects are seen in 8-10 per 1000 live births and are the commonest birth defects seen internationally. In India, it is estimated that every year, 2,40,000 children are born with a congenital heart defect, amongst whom 1/5th would require a cardiac surgery or procedure within the first year of life.
A wide variety of congenital heart defects are seen, ranging from simple defects correctable with a single procedure to complex defects that will require multiple procedures. Congenital heart defects include holes in the walls of the heart, narrowed valves, valve leaks, abnormal connections of chambers and vessels, absent or hypoplastic chambers, narrowed or hypoplastic vessels, and sometimes a combination of many defects.
Acquired Heart Defects:
Pediatric acquired heart defects are cardiac disorders that manifest later in childhood, either due to an infection, immune reaction, or various other causes. The common acquired heart defects in children are:
- Kawasaki Disease: This is a multisystem disease that affects young children where there are inflammation of blood vessels of the heart, tissues in the mouth, lips, eyes, and skin of chest, hands, and feet. Cardiac manifestations of Kawasaki disease are serious and can be life-threatening; there is dilation of the coronary arteries which are the blood vessels supplying oxygen and nutrients to the heart itself. Coronary artery involvement can be transient or permanent and can predispose to clot formation, angina, and myocardial infarction in the long term.
- Multisystem Inflammatory Syndrome in children associated with SARS-Cov-2 (MIS-C or PIMS-TS): This is a rare novel condition that is seen in COVID endemic areas, 2-4 weeks after the peak in COVID infections. MIS-C is seen following an initial COVID infection or exposure in children and was first described in the United Kingdom in April 2020. Since then, many cases have been diagnosed in Europe, North America, and also in India. In this condition, the child can have a high fever with rashes and conjunctival redness, and they often present to the hospital in a critical state with low blood pressures and loss of consciousness. This clinical presentation is known as shock and needs ICU treatment including ventilation and specific medicines to support the heart. Fortunately, if diagnosed and treated correctly, MIS-C patients have a quick, dramatic, and complete recovery, and this condition has excellent outcomes.
- Myocarditis and Cardiomyopathy: These are a group of disorders where the heart is structurally normal, but there is a problem in the function and contractility of the heart muscle. In myocarditis, there is inflammation of the heart muscle, often following a viral infection, which can lead to the transient weakening of the heart function along with heart failure. Myocarditis can also progress to dilated cardiomyopathy, where the heart pumping function is severely weakened and the heart is hugely enlarged. Dilated cardiomyopathy can be treated temporarily with medications, but severe cases may require ventricular assist devices and even heart transplantation.
- Rheumatic Heart Disease: Acute rheumatic fever is a disease of joints and the heart described in children aged 5-15 years ago following a Streptococcal sore throat infection. Rheumatic fever often involves the heart valves, and if not treated early, can progress to permanent damage of the heart valves and rheumatic heart disease. While the incidence of rheumatic heart disease has gradually reduced over the last few decades in our country, this condition can still be seen in rural areas, and the affected patients may require cardiac surgery and valve replacement.
Obesity and Acquired Cardiovascular Disease in Children:
In India, especially in the urban population, the problem of childhood obesity in school-going children is a growing problem and is poised to give rise to a major public health problem in the coming decades. The prevalence of overweight and obesity is higher in upper socioeconomic class children (17.2% overweight and 4.8% obese) as compared to lower socioeconomic class (4% and <1%, respectively), and is higher in urban compared to rural areas.
Children with obesity are at a significantly increased risk of cardiovascular disease. They have higher blood pressure (BP), abnormalities in their lipid profile and cholesterol, and insulin resistance (which can later progress to Type 2 diabetes). In fact, 70% of obese children have at least one cardiovascular disease risk factor, and 39% have two or more.
While multiple factors including genetic and hormonal influences cause obesity, the rise in the prevalence of this problem in recent years is primarily due to lifestyle and dietary factors in the general urban population.
While parents tend to ignore obesity in their children, thinking of it mainly as a “childhood problem” which the child will grow out of, the dietary, lifestyle, and exercise habits inculcated in childhood often continue into adulthood. Hence, an average of 40% (and up to 80%) of overweight children become obese as adults. Similarly, high blood pressure, lipid abnormalities, and insulin resistance which may have manifested in childhood may progress to chronic hypertension, high cholesterol, diabetes, and coronary artery disease in the patient later in life.
Childhood Obesity and Coronary Artery Disease:
Much of coronary artery disease which leads to angina and heart attacks in adults is related to a process of atherosclerosis, where cholesterol plaques form in and block the coronary arteries (vessels supplying blood, oxygen, and nutrition to the heart muscle itself). This atherosclerotic process has been shown to begin in childhood, and obesity is one of the risk factors contributing to accelerated atherosclerosis, which then persists into adulthood.
Impact of COVID-19 on Childhood Obesity:
The COVID-19 pandemic, the resultant lockdown, stopping of schools, and the closure of public playgrounds have all contributed to an effective home quarantine of most children, especially in urban areas. Unfortunately, to protect children from COVID infection, our society and municipal corporations have been forced to remove avenues for physical activity and outdoor sports for children. Hence, in these last six months of the pandemic and lockdown, when online classes have become the norm and leaving home in the evenings to play outdoors has become a rarity, the lifestyle of urban children has become more sedentary, in most cases with significant increases in their “screen-time”. While no formal research has yet been conducted on its impact, the pandemic may very well predispose to worsening incidence of childhood obesity in the next few months, which might have a lasting impact on the cardiovascular health of children.
The cardiovascular and overall health of our children defines the future health of our society as a whole. This World Heart Day, when the world is reeling under the effects of the COVID pandemic, let us strive to continue following a healthy lifestyle and dietary habits, and let us not neglect our own and our children’s cardiovascular health.