Top Things to Know: Evaluation & Management of the Child with Acute Decompensated Heart Failure
Updated: April 06, 2026
- Acute decompensated heart failure (ADHF) in children can present in many forms including unrepaired and repaired congenital heart disease, cardiomyopathies, or in special populations such as transplant rejection, and their management is tailored to the identification of their etiologies.
- ADHF can mimic common pediatric conditions including sepsis. High index of suspicion is needed before initiating sepsis protocols or administering IV fluids when the diagnosis of ADHF is a possibility.
- Hemodynamic profiles (warm, cold, wet and dry) can aid in identifying older children with ADHF, but they can be less reliable in infants and younger children. A combination of history, physical exam, laboratory and imaging studies increase the likelihood of early identification of ADHF in children.
- Inotropes are initiated in patients with symptomatic low cardiac output based on clinical assessment. Their use in the emergency department is considered safe and may provide stabilization for children awaiting ICU admission.
- Diuretics are safe and can be administered as early as congestion is identified regardless of the patient location (emergency department, inpatient floor or intensive care unit).
- A structured, rapid approach combining clinical assessment, diagnostics, and tailored therapy (medications, respiratory support) is essential for stabilizing pediatric ADHF patients in the ER. Prompt recognition and systematic management is vital to limit clinical deterioration and may improve outcomes.
- VA-ECMO is the most common form of MCS for pediatric ADHF around the world. Peripheral cannulation offers rapid deployment but can be limited by vessel size and may require a strategy for distal limb perfusion.
- Central cannulation is more commonly used after cardiac surgery with the ability to achieve higher flow rates and LV decompression. This strategy can be used for both temporary and durable VAD implantations.
- LV distension may occur while on VA-ECMO and will hamper the potential for myocardial recovery. Modes of left heart decompression include balloon atrial septostomy, direct LV or LA venting, or the addition of a percutaneous microaxial flow pump.
- A critical component of multidisciplinary care is awareness of the profound mental health burden among children and adolescents with congenital and acquired heart disease, including those with ADHF. Regular mental health screening for patients and their caregivers allows for early identification of psychological symptoms, while integrating mental health professionals, within the multidisciplinary cardiac care team facilitates timely access to specialized, evidence-based mental health treatments.
Citation
Cabrera AG, Price JF, Hong BJ, Jeewa A, Tabulov C, Wong SS, Reardon L, Kasparian NA, Amdani S; on behalf of the Young Hearts Pediatric Heart Failure and Transplantation Committee of the Council on Lifelong Congenital Heart Disease and Heart Health in the Young; the Council on Clinical Cardiology; the Council on Cardiovascular and Stroke Nursing; and the Council on Cardiovascular Radiology and Intervention. Evaluation and management of the child with acute decompensated heart failure: a scientific statement from the American Heart Association. Circulation. Published online April 6, 2026. doi: 10.1161/CIR.0000000000001428