It is a branch of science concerned with the diagnosis and treatment of diseases that develop in the heart and part of the circulatory system in children from prenatal development to 18 years of age. The branch is also involved in the prevention of cardiovascular diseases in high-risk groups. The cardiovascular system is one of the first organs to develop in the womb; it begins to form as a tube in the third week of gestation, and by about two months of age it is almost the same shape as at birth and is constantly functioning.  The development process is not always smooth and in some cases there are some problems may occur. These structural and rhythm-related abnormalities affect approximately one in every hundred born alive babies (0.8-0.9%). Technological advances have made it possible to detect such problems right in the womb. The diagnosis and treatment of congenital cardiac disease is a team effort involving obstetricians and pediatric cardiologists. Treatment methods for diseases detected postnatally differ from patient to patient and are strictly individualised, i.e. tailored to the specific patient. Some patients will recover on their own, but there are others who require serious medical intervention. Since pediatric heart defects are different from one another, the causes also vary from patient to patient. The cause of heart disease can be genetic factors, infections, unfavourable environmental conditions, exposure to chemicals, drugs, but in most cases this cause remains undetected.

 

The most common heart malformations are congenital and include heart septal defects, valve and vessel stenosis, abnormalities in the number, location, and shape of chambers, and rhythm abnormalities. There are also acquired heart defects such as rheumatic heart disease, fluid build-up in the membrane that surrounds the heart  (pericardium), diseases of the heart muscle, and diseases of the blood vessels that feed the heart (Kawasaki disease).  Covid - 19, which has affected the population in recent years, can cause problems affecting all parts of the heart and rhythm irregularities with a high enough frequency.

 

Since diseases have many different causes and variants, complaints can develop to different degrees and at different times. Many heart conditions can present with mild symptoms that a doctor may only notice on examination, in life-threatening situations haematomas can develop that require urgent intervention. The most common symptoms are listed below:

• Rapid fatigue
• Sweating
• Bruising
• Inability to gain weight
• Edema
• Rapid respiration
• Shortness of breath, dyspnea
• Frequent illness 
• Heart murmurs
• Palpitations
• Dizziness (Vertigo)
• Fainting
• Chest pain
• High blood pressure
• Inability to gain weight
• Developmental disorder

 

Pediatric heart abnormalities can be divided into congenital and acquired heart disease. Congenital heart defects are more common in children. Acquired heart disease, on the other hand, is more common in adults.

 

Malformations may include abnormalities in the location of the heart (e.g., left, right), abnormalities in the location of the heart chambers and their relationship to each other; septal openings, absent, narrow or insufficient heart valves; stenosis, dilatation, absence or opening elsewhere of vessels going to and from the heart; abnormalities in the relationship between the heart and the lungs; abnormalities of the heart muscle or membrane surrounding the heart; fast, slow or irregular heart rhythm. These diseases can be caused by the following reasons:

 

• Genetic Factors

About 0.8-0.9 per cent of newborn babies are born with heart abnormalities, about 1/10 of which are due to genetic causes. The most common genetic pathology is Down syndrome. About half of children with Down syndrome have heart disease. Thanks to advances in genetics, it has been proven that the underlying cause of many cardiovascular diseases is genetic, and new ones are added to the list every year. In many syndromes (Digeorge syndrome, Williams syndrome, Noonan syndrome), chromosome damage caused by abnormalities and breaks such as microdeletions, translocations and duplications are responsible for heart disease. A large proportion of these abnormalities can be identified through genetic counselling before and during pregnancy.

 

• Metabolic Diseases

Metabolic problems, such as maternal diabetes mellitus (diabetes) or high gestational diabetes mellitus, account for 1% to 2% of all heart disease in newborns. The risk of cardiovascular disease in children born to diabetic mothers is 2-6%. Meanwhile, a mother's weight gained during pregnancy and blood sugar levels have a much greater impact on her child's risk of developing conditions such as hypertension, diabetes and cardiovascular disease later in life than was previously thought.

 

• Infectious diseases

Infections the mother has undergone during pregnancy are the cause of many cardiovascular diseases. Infectious diseases such as rubella, CMV, toxoplasmosis, and herpes carried during pregnancy have a particularly negative impact on the baby's heart. The Covid-19 infection that we have encountered in recent years can also have an adverse effect on the baby's heart.

 

• Teratogenic Factors

Smoking, alcohol, drug use, exposure to X-rays and chemicals, and taking certain medications during pregnancy can cause congenital heart defects. Another danger affecting the baby's heart health is environmental pollution - the air a mother breathes in during pregnancy and everything she eats and drinks.

 

• Medications

The medications taken by the mother before pregnancy and the medications used during pregnancy affect the health of the baby. Some of them may also cause heart problems.

 

If there is any suspicion after obtaining a detailed medical history and physical examination, cardiac imaging or function testing may be required. It is up to the examining physician to decide which test to perform and when to perform it.

 

This is the most commonly used method, which is essentially an ultrasound scan of the heart. To the best of the knowledge, this diagnostic method does not pose a significant risk to the patient. The method involves imaging the heart while simultaneously working with high-frequency sound waves. The procedure is performed by a physician using an echocardiography device. Echocardiography can be performed directly over the surface of the chest or with a probe placed in the oesophagus (transesophageal echocardiography). Sometimes, doctors mention the need to perform colour Doppler ultrasound. To avoid confusion, it is important to know that all the modern echocardiographic machines used today can also perform colour Doppler studies. Remember that echocardiography procedure also includes colour Doppler imaging Also, the echocardiography machine has options of two-dimensional, three-dimensional and four-dimensional echocardiographic examination. Which method is best suitable for the patient will be determined by the pediatric cardiologist who will provide the necessary information. In general, three- and four-dimensional echocardiography for children has no greater advantage over two-dimensional echocardiography compared to adults. This means that two-dimensional chest examination is generally sufficient for pediatric patients. 

 

The method consists of recording the electrical activity of the heart using electrodes attached at various locations on the skin of the chest. Electrocardiography has been used for about 120 years, it has no significant side effects and provides the doctor with information about the rhythm of the heart and whether it is functioning properly. It is performed painlessly, quickly and can detect many conditions such as heart arrhythmias and conductivity disorders, myocardial infarction, heart muscle diseases (thickening of the heart walls, inflammation of the heart muscle). When interpreting the results, it should be borne in mind that there is some variation in norms for children depending on the age group.

 

The heart is a continuously working organ and is able to change its velocity and mode of operation instantaneously. With a conventional ECG, the rhythm can only be monitored for a short time. To detect rhythm disturbances that may occur throughout the day, a small device with electrodes attached to the chest wall, similar to an ECG, and is used to provide a 24-hour recording of heart activity. Holter monitoring is performed for complaints such as short-term rhythm disturbances, fainting, sudden weakness and shortness of breath. The ECG continuously records the rhythm and function of the heart throughout the day's activity. The recorded data is evaluated by a pediatric cardiologist, identifying and recording any abnormalities.

 

Most heart problems in children can be detected using relatively safe and non-intrusive methods such as echocardiography and ECG. However, in some cases it may be necessary to measure and visualise the heart using special drugs injected into it. This method is called "angiography" or "cardiac catheterisation" and is an examination of the vessels leading to and from the heart and the valves of the heart chambers through vessels in the leg or arm. Whereas angiography and cardiac catheterisation were previously used mainly for diagnostic purposes, today they are used to perform surgical interventions such as closing heart septal openings, opening vessel and valve stenoses, altering blood flow in the heart, and opening blocked vessel New, more effective and reliable methods of diagnosis and treatment are being developed through the use of technological advancements. Although this method is more discomforting to the patient compared to ECHO and ECG, it is increasingly being used because it reduces the need for major interventions such as surgery, it is easy to perform, and it does not significantly affect the patient's quality of life.

 

It is a technique that is based on the evaluation of the shadow of the heart on X-ray film and, provides information about heart failure, location of the heart, and diseases of the membranes surrounding the heart. Ince the amount of radiation produced in the process is small, there is no danger involved in the use of this diagnostic method. However, family members should be informed that the procedure involves receiving a small dose of radiation. Nowadays, telecardiography is used less and less due to the increasing diagnostic value of other methods.

 

This method is used in the diagnosis and treatment of heart rhythm irregularities. Electrical signals obtained directly through catheters inserted into the heart are used to assess the state of impulse conduction, after which the identified irregularities are treated using various methods. Syncope, tachycardia, and complex heart rhythm disorders are especially often diagnosed and treated using this method. It is one of the most commonly used high-tech procedures. In some cases, with this procedure, truly miraculous results can be achieved. 

 

Many heart conditions cannot be diagnosed at a resting state. Therefore, this examination is performed using devices such as treadmills and exercise bikes that allow a controlled increase in cardiac workload. The heart's response to increased workload is used to diagnose many conditions or to assess response to treatment. During the test, ECG and blood pressure are measured and monitored using electrodes attached to the chest.

 

An examination by a pediatric cardiologist is recommended if the pediatrician notes the possibility of heart problems, if one or more of the above complaints are present, or if the obstetrician detects heart abnormalities on an intrauterine ultrasound. It is also recommended to consult a pediatric cardiologist if there is a family history of early-onset heart disease, infections such as rubella and chickenpox during pregnancy, and abnormalities that predispose to heart disease, such as Down syndrome.

 

Reasons for referral to a pediatric cardiologist include the presence of a history of heart disease or identification by the pediatrician of cardiac risk, detection of heart murmurs when listening to the heart, detection of a condition that may lead to heart disease, one or more complaints such as bruising, chest pain, fainting, palpitations.

 

• Heart Murmur:

A heart murmur is a whooshing or swishing sound  that is present among the normal heart sounds while listening to the heart with a stethoscope. A distinction is made between organic heart murmurs (indicating cardiac pathology) and functional ("innocent" murmurs). The sound heard in a functional murmur is not associated with any heart disease and is not always heard, decreases when standing and increases when lying down. This is because the chest wall in children is thinner than in adults. As the child grows, this wall thickens and the heart moves deeper inwards so that the murmur becomes inaudible. Pathological murmurs are caused by structural abnormalities such as openings in the cardiac septa, abnormalities of the vascular lumen, stenosis of vessels and heart valves. A healthcare practitioner can easily identify the type of heart murmurs. After examination and evaluation by a pediatric cardiologist, a differential diagnosis is conducted, primarily by using echocardiography.

 

• Chest pain:

Chest pain is a common complaint in childhood, but unlike in adults, it is very rare for chest pain to be related to the heart. The most common heart conditions that cause chest pain are thickening and weakening of the heart muscle, certain valve malformations, fluid accumulation between the heart and the membrane surrounding the heart, stenosis, obstruction or impaired outflow from the vessels that feed the heart (coronary vessels). Covid-19 is also one of the causes of heart-related chest pain. Up to 98% of patients experience non-cardiac chest pain. Nevertheless, in most patients, examination and evaluation by a pediatric cardiologist are required to determine the source of pain.

 

• Infective endocarditis:

It is an inflammation of heart valves' lining and sometimes heart chambers' lining. It is common in children with structural heart disease or a medical history of operated heart defects. Prevention of infective endocarditis is recommended for most patients with congenital heart disease, including those who have undergone surgery. The most important step in prevention is to pay close attention to your oral and dental health. Another part is the use of appropriate antibiotics before any procedure involving the mouth, teeth, digestive system, urinary tract and respiratory system that can cause bleeding. The infection itself is a fairly serious condition, the treatment of which is difficult, lengthy and sometimes unsuccessful. Therefore, prevention is of utmost importance.  

 

Most heart problems occur when there is an increased workload on the heart. Sport is known to be one of the factors that increase the workload of the heart. A child or young athlete who has no problems with normal daily activities may have problems during a sporting activity.  And at the most intense exertion, sudden fatalities can occur. It has been known since the early 1900s that playing sports is a risk factor in this regard. The problem we shall focus on is the identification of children and adolescents at risk. Our goal here is to prevent possible dangerous situations by using appropriate treatment and prevention methods. The most common and serious of the conditions that can cause problems when playing sports is a pathology manifested by thickening of the heart muscle, in most cases inherited genetically. A large proportion of these diseases are difficult to differentiate as they may occur in the absence of any clinical manifestations or complaints preceding the disease onset. Other conditions include structural heart disease, weakness or inflammation of the heart muscle, increased stress on the front wall of the heart, stenosis or obstruction of the coronary arteries feeding the heart, and rhythm disturbances. The overall value of patient history, examination, and ECG is limited in the diagnosis of these conditions. Most important here is direct examination of the heart with echocardiography. Holter monitoring and a Treadmill Exercise Test may also be required if necessary. After these tests, it can be determined whether or not a child can play sports, what sports they can play and the extent to which they can play. In fact, pre-sport health assessment should be recommended for all children, but because its availability is limited, it is particularly important for children at risk.

 

The following groups are at risk: those with a family history of heart disease, onset before the age of 50, sudden mortality in the family history, those with structural heart disease, heart rhythm irregularities, and problems such as heart muscle disease or Kawasaki disease are the groups that are recommended to be screened before playing sports. Since 99% of problems are of cardiological origin, it is preferable to have a pediatric cardiologist perform the examination. Intense activity puts a lot of strain on the heart. A pediatric cardiologist will examine your child for life-threatening conditions such as heart attack, as well as abnormalities that may occur during heavy sports and exercise. In order to prevent complications, most of which are due to congenital heart disease, heart muscle disease and arrhythmias, it is recommended that children who regularly participate in sports be examined by a pediatric cardiologist once a year.

 

Ekleme Tarihi: 8/8/2023
Güncelleme Tarihi: 8/8/2023
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