Editor,—The article by Westabyet al presented concisely recent developments in the management of infants and children with congestive cardiac failure.1 We would like to highlight the following additional points.

A better understanding of pathophysiology has shifted medical management from steps that directly improve myocardial function to those that modulate the neuroendocrine profile and peripheral vascular reactivity. Similar advances in therapeutic applications would be assisted by controlled studies and full licensing of drugs for use in children. Medical intervention will remain the cornerstone of management until advances in surgical techniques become more widely available.

Although digoxin does not improve survival it provides symptomatic relief and reduces hospital admissions for exacerbations.2 Loop diuretics lose efficacy over time; this “breaking phenomenon” can be overcome by combination with metolazone, producing sequential segmental nephron blockade.3 The recently published results of RALES (randomized aldactone evaluation study)4 have shown significant survival benefits from the use of spironolactone, an aldosterone receptor antagonist when used with an angiotensin converting enzyme inhibitor and loop diuretic. This combination necessitates careful monitoring for hyperkalaemia, but reduces the need for oral potassium supplements, which have a bitter taste and are poorly accepted by children. Compliance with medication can be enhanced by assisting the family to choose the “best-fit” regimen (concordance).5

Attention to psychological problems arising from the restricted lifestyle and frequent diagnostic and therapeutic interventions can improve prognosis and outcome. Additionally, young children may not understand the benefits of treatment, and adolescents may exhibit independence or denial. However, despite many limitations the prognosis for children with severe heart failure has significantly improved over the past decade.6 7