Paediatric: Cardiology Respiratory

• Respiratory basics: Assessing the Breathless Child | Noisy Breathing in Infants
• Acute infections: Bronchiolitis | Croup | Pneumonia | Whooping Cough | Choking and Inhaled Foreign Body
• Chronic conditions: Preschool Wheeze | Asthma — Diagnosis | Asthma — Long-term Treatment | Acute Asthma | Cystic Fibrosis | Chronic Cough and Other Lung Conditions
• Heart: Heart Murmurs | Acyanotic Congenital Heart Disease | Cyanotic Congenital Heart Disease | Heart Failure in Infants | Arrhythmias, Chest Pain and Syncope | Acquired Heart Disease
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🫁 Respiratory and heart problems in children — breathing problems are the commonest reason children are admitted to hospital, especially bronchiolitis in winter. Asthma is the commonest chronic illness of childhood, and children still die from it in the UK. Most heart murmurs in children are innocent, but congenital heart disease affects about 1 in 100 babies.
Your four questions for every child: How hard is the child working to breathe (rate, recession, saturations, feeding)? Is there stridor (upper airway) or wheeze (lower airway)? What is the age — and does that fit the diagnosis? Could this be the heart (murmur, cyanosis, hepatomegaly, poor feeding)?

Assessing the Breathless Child

• Signs of increased work of breathing:
  • Fast breathing; recession (subcostal, intercostal, sternal, tracheal tug).
  • Nasal flaring; head bobbing (infants); grunting (a sign of severe distress).
  • Accessory muscle use; tripod position.
  • Difficulty feeding or talking.
• Signs of exhaustion (pre-arrest) — slowing breathing rate, reduced effort, falling heart rate, drowsiness, cyanosis, silent chest.
• Noises:
  • Stridor — harsh, mainly inspiratory: upper airway (croup, laryngomalacia, epiglottitis, foreign body, anaphylaxis).
  • Wheeze — musical, mainly expiratory: lower airways (bronchiolitis, asthma, viral wheeze).
  • Crackles — bronchiolitis, pneumonia, heart failure.
• Oxygen saturation — normally 95% or more; under 92% needs oxygen and usually admission.

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Noisy Breathing in Infants

• Laryngomalacia — the commonest cause of stridor in infants:
  • Floppy tissues above the vocal cords collapse inwards on breathing in.
  • Inspiratory stridor from the first weeks, worse when feeding, crying, lying on the back, or with colds; otherwise well and thriving.
  • Usually resolves by 12–18 months.
  • Refer if severe — faltering growth, apnoea, cyanosis, recession (surgery — supraglottoplasty).
• Other causes — subglottic stenosis (after intubation), vocal cord palsy, haemangioma (with skin haemangiomas — "beard" distribution; propranolol), vascular ring, tracheomalacia (expiratory noise).
• Snoring — adenotonsillar hypertrophy; obstructive sleep apnoea (see the Nose and Throat chapter).

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Bronchiolitis

• What it is: A viral lower respiratory tract infection of children under 2 (mostly under 1, peak 3–6 months), usually RSV. Winter epidemics (October to March).
• Features (NICE NG9):
  • Coryza (runny nose) for 1–3 days, then persistent cough.
  • Fast breathing and/or chest recession.
  • Wheeze and/or fine inspiratory crackles.
  • Poor feeding; low-grade fever (high fever over 39 °C — think pneumonia).
  • Apnoea — may be the only sign in young infants.
  • Symptoms peak at day 3–5; cough can last 4 weeks.
• Higher risk of severe disease — under 3 months (especially under 6 weeks), preterm birth, chronic lung disease, congenital heart disease, neuromuscular disease, immunodeficiency.
• Refer or admit if:
  • Apnoea (observed or reported).
  • Oxygen saturation persistently under 92% in air.
  • Inadequate fluid intake (50–75% of normal) or no wet nappy for 12 hours.
  • Severe respiratory distress — grunting, marked recession, breathing rate over 70.
  • Looks seriously unwell; central cyanosis.
  • Risk factors or social concerns (lower threshold).
• Management — supportive:
  • Oxygen if saturations persistently under 92% (nasal cannula; high-flow or CPAP if worsening).
  • Fluids and feeding — small frequent feeds; NG or OG tube feeds if not feeding well; IV fluids if NG not tolerated (risk of hyponatraemia — isotonic fluids).
  • Nasal suction only if secretions cause distress or feeding problems, or apnoea.
  • Don't use — salbutamol, ipratropium, adrenaline, steroids, antibiotics, hypertonic saline, montelukast, chest physiotherapy.
  • Blood gas if severe (rising CO2 — respiratory failure).
• Prevention:
  • RSV vaccine in pregnancy (from 28 weeks) — protects infants in the first months.
  • RSV monoclonal antibody (nirsevimab; palivizumab previously) for high-risk infants.
  • Handwashing; avoiding smoke exposure.
• Safety-net — worsening breathing, pauses in breathing, blue lips, poor feeding or fewer wet nappies, exhaustion.

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Croup

• What it is: Laryngotracheobronchitis — viral swelling of the upper airway, usually parainfluenza. Ages 6 months to 3 years; autumn peak.
• Features:
  • Coryza and mild fever, then a barking ("seal-like") cough.
  • Inspiratory stridor; hoarse voice.
  • Worse at night; settles in 2–3 days.
  • The child usually looks well.
• Severity (e.g. Westley score):
  • Mild — barking cough, no stridor at rest.
  • Moderate — stridor at rest, some recession, not agitated.
  • Severe — stridor at rest, marked recession, agitation or lethargy, tachycardia.
  • Impending respiratory failure — decreasing consciousness, cyanosis, reduced stridor and air entry (fatigue).
• Management:
  • Keep the child calm (on a parent's lap); don't examine the throat or upset them.
  • Oral dexamethasone 0.15 mg/kg single dose for all severities (oral prednisolone 1–2 mg/kg, or nebulised budesonide if vomiting).
  • Severe — nebulised adrenaline (400 micrograms/kg of 1:1,000, maximum 5 mg/5 mL) — works quickly but wears off in 2 hours (observe); oxygen; senior anaesthetic and ENT help; intubation rarely.
  • Admit if moderate to severe, under 6 months, recurrent, or not improving.
  • Steam and humidified air are not effective.
• Differentials (if stridor is severe or atypical):
  • Epiglottitis — toxic, drooling, high fever, no barking cough, sits forward (rare since Hib vaccine).
  • Bacterial tracheitis — croup-like but high fever, toxic, thick secretions, poor response to treatment.
  • Inhaled foreign body — sudden onset, no prodrome.
  • Anaphylaxis; retropharyngeal abscess.
  • Spasmodic croup — recurrent, sudden at night, no fever (atopic children).

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Pneumonia

• Causes:
  • Viruses — the commonest under 2 (RSV, influenza, rhinovirus, metapneumovirus).
  • Streptococcus pneumoniae — the commonest bacterial cause at all ages.
  • Mycoplasma pneumoniae — school-age children (headache, sore throat, rash, gradual onset).
  • Group A strep and Staph aureus (after influenza or chickenpox — severe, empyema).
  • Neonates — GBS, Gram-negatives.
• Features — fever, cough, fast breathing, recession, crackles or bronchial breathing, reduced breath sounds; abdominal pain (lower lobe), neck stiffness (upper lobe); wheeze makes bacterial pneumonia less likely.
• Tests:
  • Chest X-ray is not routine — do it if severe, not improving, or complications suspected.
  • Oxygen saturation; FBC, CRP and blood cultures if admitted.
• Admit if — saturations under 92%, severe distress, grunting, apnoea, not feeding, dehydrated, or under 3 months.
• Treatment (NICE NG138):
  • Amoxicillin for 5 days (oral) — first line.
  • Clarithromycin (or erythromycin) if penicillin allergic, or atypical (Mycoplasma) suspected.
  • Co-amoxiclav if after influenza, complicated, or aspiration.
  • IV antibiotics if severe or unable to take oral.
  • Many mild cases in young children are viral and don't need antibiotics.
• Complications:
  • Parapneumonic effusion and empyema — persistent fever after 48 hours of antibiotics, chest pain, dull to percussion: ultrasound, chest drain, fibrinolytics, or surgery.
  • Lung abscess; necrotising pneumonia; sepsis; HUS (pneumococcal).
• Recurrent pneumonia — consider inhaled foreign body, aspiration, cystic fibrosis, immunodeficiency, congenital lung malformation, primary ciliary dyskinesia, heart disease.

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Whooping Cough

• Bordetella pertussis — very infectious; large UK outbreaks (e.g. 2024); most dangerous in babies under 3 months (deaths in unvaccinated infants).
• Stages:
  • Catarrhal (1–2 weeks) — cold-like symptoms (most infectious stage).
  • Paroxysmal (2–8 weeks) — bouts of coughing, often worse at night, followed by an inspiratory "whoop", vomiting after coughing, red or blue face; well between bouts.
  • Convalescent — weeks to months ("100-day cough").
• Infants — may not whoop; apnoea, cyanosis, feeding difficulty, seizures; complications include pneumonia, pulmonary hypertension, brain injury.
• Diagnosis:
  • PCR on a nasopharyngeal swab (within 2–3 weeks of cough onset).
  • Serology (anti-pertussis toxin IgG) or oral fluid test later.
  • FBC — marked lymphocytosis.
• Management:
  • Macrolide if within 21 days of cough onset (reduces spread, not symptoms) — azithromycin (under 1 month and others) or clarithromycin; co-trimoxazole if macrolides unsuitable.
  • Admit infants under 6 months who are unwell, have apnoea or cyanosis, or feed poorly.
  • Notify UKHSA; antibiotic prophylaxis for close contacts in priority groups (e.g. infants, pregnant women).
  • Exclude from school for 48 hours after starting antibiotics (or 21 days from cough onset if not treated).
• Prevention — maternal pertussis vaccine in every pregnancy (from 16 weeks); infant 6-in-1 vaccines; pre-school booster.

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Choking and Inhaled Foreign Body

• Choking (Resuscitation Council UK):
  • Effective cough (can cry, cough, breathe) — encourage coughing; watch closely.
  • Ineffective cough, conscious:
    • Infants (under 1) — up to 5 back blows (head down, along the thigh) then up to 5 chest thrusts (two fingers on the lower sternum).
    • Children over 1 — up to 5 back blows then up to 5 abdominal thrusts.
    • Repeat; call for help.
  • Unconscious — open the airway, 5 rescue breaths, start CPR.
  • Avoid blind finger sweeps.
• Inhaled foreign body (peanuts, small toys, seeds — mainly 1–3 year olds):
  • Sudden choking episode then persistent cough; may seem to settle.
  • One-sided wheeze or reduced breath sounds; recurrent pneumonia in the same lobe (usually the right main bronchus).
  • Chest X-ray — most objects are not visible; air trapping (hyperinflation on the affected side, best seen on an expiratory film), collapse.
  • Rigid bronchoscopy to remove it — don't wait for X-ray changes if the history is suggestive.
• Swallowed button batteries and magnets — emergencies (see the ENT Emergencies chapter).

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Preschool Wheeze

• Very common in children under 5 — about a third wheeze at some point; most grow out of it.
• Patterns:
  • Episodic viral wheeze — wheeze only with colds, well between episodes; usually outgrown by school age.
  • Multiple-trigger wheeze — wheeze with colds and other triggers (exercise, allergens, smoke) and between episodes; more likely to become asthma (especially with eczema, allergies or family history of atopy).
• Acute episode — salbutamol via spacer and mask; oral prednisolone is not routinely recommended for viral wheeze in under-5s unless admitted and severe.
• Prevention (NICE NG245, children under 5 with suspected asthma):
  • An 8–12 week trial of twice-daily paediatric moderate-dose inhaled corticosteroid, with salbutamol as needed.
  • Stop at the end of the trial — if symptoms return, restart low-dose ICS; a leukotriene receptor antagonist (montelukast) is an add-on or alternative.
  • Diagnosis of asthma is confirmed later, when the child can do objective tests (from about 5).
• Avoid smoke exposure; inhaler technique with a spacer and mask.

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Asthma — Diagnosis

• Symptoms — wheeze, cough (especially at night and with exercise), breathlessness, chest tightness; variable and triggered by viral infections, exercise, cold air, allergens (pets, dust mite, pollen), smoke; personal or family history of atopy (eczema, hay fever).
• Objective tests (BTS/NICE/SIGN NG245), children 5–16:
  • FeNO (fractional exhaled nitric oxide) — 35 ppb or more supports asthma.
  • If FeNO isn't available or is normal — spirometry with bronchodilator reversibility (FEV1 increase of 12% or more).
  • Peak flow variability (over 20% over 2 weeks) or skin prick / IgE / eosinophil count to support.
  • Children under 5 — clinical diagnosis based on pattern and response to treatment.
• Features suggesting something else — symptoms from birth, wet productive cough, faltering growth, finger clubbing, focal signs, persistent one-sided wheeze, stridor, recurrent pneumonia — consider CF, foreign body, primary ciliary dyskinesia, immunodeficiency, aspiration, congenital abnormalities, heart disease.

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Asthma — Long-term Treatment

• Children 5–11 (NICE NG245 algorithm):
  • Newly diagnosed — twice-daily paediatric low-dose ICS, with a SABA (salbutamol) reliever.
  • Uncontrolled — if the child can manage it, low-dose MART (maintenance and reliever therapy with ICS/formoterol — off-label under 12); if not, add a leukotriene receptor antagonist (montelukast) for 8–12 weeks (stop if not effective).
  • Still uncontrolled — moderate-dose MART, or twice-daily ICS/LABA combination (± LTRA) with SABA.
  • Still uncontrolled — refer to a specialist.
• Young people 12 and over — as for adults: as-needed ICS/formoterol (anti-inflammatory reliever, AIR) first line, then MART (see the Airways Disease chapter).
• "Uncontrolled" means — any attack needing oral steroids, or reliever use on 3 or more days a week, or waking at night once a week or more.
• Before stepping up, check:
  • Inhaler technique (pMDI with a spacer for all children; mask for young children); adherence.
  • Smoke or vape exposure; mould and damp housing; allergens; alternative diagnoses; psychosocial factors.
• Every child should have:
  • A personalised asthma action plan (written).
  • A yearly asthma review (and after every attack); school asthma plan and spare inhaler.
  • Influenza vaccination.
• Side effects of ICS — oral thrush and hoarseness (spacer, rinse mouth), small effect on growth (monitor height at higher doses), adrenal suppression at high doses (steroid card).
• Montelukast — MHRA warning about neuropsychiatric effects (sleep disturbance, nightmares, agitation, low mood, suicidal thoughts) — warn families.
• SABA overuse — using 3 or more salbutamol inhalers a year is a marker of poor control and increased risk of death.

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Acute Asthma

• Treatment:
  • Oxygen to keep SpO2 94–98%.
  • Salbutamol — via pMDI and spacer, 1 puff at a time, up to 10 puffs, repeated every 20–30 minutes as needed; nebulised salbutamol (2.5 mg under 5, 5 mg over 5) with oxygen if severe or life-threatening ("back-to-back" if needed).
  • Ipratropium bromide nebulised (250 micrograms) — add if poor response to salbutamol (severe).
  • Oral prednisolone — early (within the first hour): 1–2 mg/kg (age 2–5: 20 mg; over 5: 30–40 mg; maximum 40 mg) for 3 days; IV hydrocortisone if vomiting or very unwell.
  • If not responding — IV magnesium sulfate (40 mg/kg, maximum 2 g, over 20 minutes); IV salbutamol; IV aminophylline (in PICU settings); senior and PICU review.
  • Chest X-ray only if pneumothorax, consolidation or life-threatening features.
  • Blood gas — a normal or rising pCO2 in a child with severe asthma is a sign of exhaustion.
  • Antibiotics are not routinely needed.
• Discharge — when stable on salbutamol every 3–4 hours; check inhaler technique; action plan; complete prednisolone; GP review within 2 working days; consider stepping up preventer.
• Risk factors for fatal asthma — previous ICU admission, frequent attacks, heavy SABA use, poor adherence, psychosocial problems, adolescents.

⚠️ Safety Pearl: A quiet chest in a child with asthma is not good news — a silent chest, drowsiness and a "normal" CO2 mean the child is tiring and close to respiratory arrest. Call for senior and PICU help.

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Cystic Fibrosis

• What it is: An autosomal recessive condition (about 1 in 2,500 UK babies; carriers about 1 in 25) caused by variants in the CFTR chloride channel gene — the commonest is F508del. Thick secretions affect the lungs, pancreas, gut, liver and reproductive tract.
• Diagnosis:
  • Newborn blood spot screening (raised immunoreactive trypsinogen, then gene testing).
  • Sweat test — chloride 60 mmol/L or more confirms.
  • Genetic testing.
• Features:
  • Newborn — meconium ileus (bowel obstruction), prolonged jaundice.
  • Lungs — recurrent chest infections, chronic wet cough, bronchiectasis; infections with Staph aureus, Haemophilus, Pseudomonas aeruginosa, Burkholderia cepacia, non-tuberculous mycobacteria; nasal polyps, sinusitis.
  • Gut — pancreatic insufficiency (pale, bulky, greasy, smelly stools — steatorrhoea; faltering growth); distal intestinal obstruction syndrome; rectal prolapse.
  • Other — CF-related diabetes, CF liver disease, finger clubbing, salt loss in heat, male infertility (absent vas deferens), osteoporosis.
• Management (specialist CF centre, MDT):
  • CFTR modulators — e.g. elexacaftor/tezacaftor/ivacaftor (Kaftrio) for eligible variants (most patients) — dramatically improve lung function and weight.
  • Airway clearance — daily chest physiotherapy, exercise.
  • Mucolytics — dornase alfa, hypertonic saline.
  • Antibiotics — prophylactic flucloxacillin (young children, in many centres); treat infections promptly; Pseudomonas eradication and nebulised antibiotics (tobramycin, colistin).
  • Nutrition — pancreatic enzyme replacement (Creon) with meals and snacks; high-calorie, high-fat diet; fat-soluble vitamins (A, D, E, K); salt supplements.
  • Infection control — patients shouldn't meet each other (cross-infection).
  • Screen for diabetes and liver disease; lung transplant in end-stage disease.
• Life expectancy — now over 50 years and improving with modulators.

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Chronic Cough and Other Lung Conditions

• Chronic cough (over 4 weeks in children) — causes:
  • Post-viral cough (common); asthma; pertussis.
  • Protracted bacterial bronchitis — wet cough for over 4 weeks in a young child, otherwise well; responds to 2 weeks of co-amoxiclav.
  • Inhaled foreign body; aspiration (neurodisability, reflux).
  • Cystic fibrosis; primary ciliary dyskinesia; bronchiectasis; immunodeficiency; TB.
  • Upper airway (postnasal drip); habit cough (disappears during sleep); smoke exposure.
• Red flags — wet productive cough, faltering growth, clubbing, haemoptysis, chest deformity, neonatal onset, cough with feeding.
• Primary ciliary dyskinesia — autosomal recessive: neonatal breathing problems, year-round wet cough and runny nose from birth, recurrent otitis media and glue ear; half have situs inversus (Kartagener syndrome); later bronchiectasis and infertility.
• Congenital lung malformations — congenital pulmonary airway malformation, sequestration — often found on antenatal scans.
• Bronchopulmonary dysplasia — chronic lung disease of prematurity (see the Neonatology chapter).

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Heart Murmurs

• Innocent murmurs are very common (up to half of children at some point), often heard during a fever or illness.
• Features of an innocent murmur (the "4 S's" and more):
  • Soft (grade 1–2).
  • Systolic (never diastolic).
  • Short, at the left sternal edge.
  • Symptomless child.
  • Changes with position (sitting or standing).
  • Normal heart sounds, no thrill, no radiation, normal pulses.
• Types — Still's murmur (vibratory, left sternal edge), venous hum (continuous, below the clavicle, disappears when lying down or pressing on the neck), pulmonary flow murmur.
• Features suggesting a pathological murmur:
  • Diastolic, pansystolic or continuous (not a venous hum).
  • Loud (grade 3 or more), with a thrill, or radiating.
  • Abnormal heart sounds (fixed split S2, single S2), clicks.
  • Symptoms — breathlessness, poor feeding, faltering growth, sweating with feeds, cyanosis, syncope, chest pain on exercise.
  • Weak or absent femoral pulses (coarctation).
  • Murmur in a newborn or in a child with a syndrome (Down, Turner, Williams, 22q11, Noonan).
• Investigations — four-limb BP, pre- and post-ductal saturations, ECG, chest X-ray, echocardiogram (definitive).

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Acyanotic Congenital Heart Disease

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Cyanotic Congenital Heart Disease

• Tetralogy of Fallot — the commonest cyanotic lesion overall:
  • Four features — VSD, overriding aorta, right ventricular outflow (pulmonary) obstruction, right ventricular hypertrophy.
  • Cyanosis (variable — worse with more outflow obstruction); ejection systolic murmur (from the pulmonary stenosis); "boot-shaped" heart on X-ray.
  • Hypercyanotic ("tet") spells — sudden worsening cyanosis, irritability, breathlessness, sometimes collapse, often after crying or feeding. Older children squat instinctively. Treatment — knee-to-chest position, oxygen, morphine, IV fluids, propranolol, phenylephrine.
  • Association — 22q11 deletion (DiGeorge).
  • Surgical repair at about 6 months.
• Transposition of the great arteries (TGA) — the aorta comes off the right ventricle and the pulmonary artery off the left (two parallel circulations):
  • Severe cyanosis in the first days of life (as the duct closes), often with no murmur; "egg on a string" on X-ray.
  • Prostaglandin to keep the duct open; balloon atrial septostomy; arterial switch operation in the first weeks.
  • Linked to maternal diabetes.
• Other cyanotic lesions — tricuspid atresia, pulmonary atresia, total anomalous pulmonary venous drainage, truncus arteriosus, hypoplastic left heart syndrome (collapse when the duct closes; staged surgery — Norwood, Glenn, Fontan).
• Eisenmenger syndrome — an untreated left-to-right shunt (VSD, AVSD, PDA) causes pulmonary hypertension, then the shunt reverses: late cyanosis, clubbing, polycythaemia. Prevented by early repair.
• Long-term — many survive to adulthood (grown-up congenital heart disease clinics); endocarditis risk; arrhythmias; pregnancy planning. See the Congenital Heart Disease chapter.

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Heart Failure in Infants

• Causes — large left-to-right shunts (VSD, AVSD, large PDA), left heart obstruction (coarctation, aortic stenosis, HLHS), cardiomyopathy, myocarditis, arrhythmias (SVT), severe anaemia.
• Features:
  • Poor feeding, breathless or sweaty during feeds, taking a long time to feed.
  • Faltering growth.
  • Fast breathing, recession, recurrent chest infections.
  • Hepatomegaly (liver edge felt well below the ribs) — a key sign in infants (peripheral oedema is rare).
  • Tachycardia, gallop rhythm, cardiomegaly.
• Management — diuretics (furosemide, spironolactone); ACE inhibitors (captopril) in some; high-calorie feeds, NG feeding; treat anaemia; surgery or catheter intervention for the underlying defect.

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Arrhythmias, Chest Pain and Syncope

• Supraventricular tachycardia (SVT) — the commonest arrhythmia in children:
  • Infants — heart rate over 220, poor feeding, pallor, irritability, heart failure if prolonged. Older children — rate over 180, palpitations, chest discomfort, dizziness.
  • Treatment — if stable: vagal manoeuvres (infants — ice-cold water or a bag of ice on the face; older children — blowing into a syringe, modified Valsalva); then IV adenosine (rapid bolus, increasing doses); if shocked — synchronised DC cardioversion.
  • Wolff–Parkinson–White syndrome (delta wave) — refer.
• Chest pain in children — usually musculoskeletal (costochondritis), respiratory, reflux, or anxiety. Cardiac causes are rare: exertional pain or syncope, pericarditis, myocarditis, Kawasaki (coronary), cocaine, aortic dissection (Marfan).
• Syncope (fainting):
  • Vasovagal — the commonest: standing, heat, pain, sight of blood; warning symptoms (light-headed, hot, nausea, tunnel vision); quick recovery.
  • Red flags (refer urgently to cardiology) — syncope during exercise, triggered by loud noises or swimming, with palpitations or chest pain, while lying down, a family history of sudden death under 40, abnormal ECG or examination.
  • Causes to exclude — long QT syndrome, hypertrophic cardiomyopathy, Brugada syndrome, catecholaminergic VT, aortic stenosis, WPW.
  • ECG for every child with syncope.
• Reflex anoxic seizures and breath-holding spells (toddlers) — after a bump or upset: going pale or blue, brief loss of consciousness, sometimes jerks; benign; reassurance (check FBC — iron deficiency in breath-holding).

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Acquired Heart Disease

• Kawasaki disease — coronary artery aneurysms (see the Paediatric Infections chapter).
• Myocarditis — viral (enteroviruses, COVID-19), PIMS-TS; breathlessness, chest pain, tachycardia out of proportion to fever, arrhythmias, heart failure, sudden death. Troponin, ECG, echo; supportive care in PICU.
• Pericarditis — sharp chest pain, better sitting forward, friction rub; viral, bacterial (purulent), post-surgical.
• Infective endocarditis — children with congenital heart disease (especially after surgery or with prosthetic material): prolonged fever, new murmur, splenomegaly, embolic signs. Blood cultures, echo, prolonged IV antibiotics. Good dental hygiene is key; antibiotic prophylaxis is not routinely recommended in the UK (NICE).
• Acute rheumatic fever — rare in the UK, common worldwide: after group A strep throat infection — carditis, polyarthritis, Sydenham's chorea, erythema marginatum, subcutaneous nodules (Jones criteria); penicillin prophylaxis; rheumatic valve disease (mitral).
• Cardiomyopathy — hypertrophic (family screening, sudden death risk), dilated (myocarditis, genetic, muscular dystrophies, anthracyclines).
• Hypertension in children — usually secondary in younger children (kidney disease, coarctation, endocrine); primary hypertension in obese teenagers. Use age-, sex- and height-specific centiles.

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Drug Reference Table

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Spot the Diagnosis