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Melanie Cole (Host): There’s no handbook for your child’s health, but we do have a podcast, featuring world class clinical and research physicians covering everything from your child’s allergies to zinc levels. Welcome to Kids Health Cast by Weill Cornell Medicine. I’m Melanie Cole. And I invite you to listen as we’re discussing general concerns that parents may have around cardiac health for their kids.

Joining me in this panel is Dr. Patrick Flynn. He’s an Associate Professor of Clinical Pediatrics at Weill Cornell Medicine and an Associate Attending Pediatrician at New York Presbyterian Hospital Weill Cornell Medical Center. And Dr. Ken Bayle. He’s an Assistant Professor of Pediatrics and an Assistant Attending Pediatrician at Weill Cornell Medicine New York Presbyterian Queens.

Doctors, thank you so much for joining us today and this is such a really important topic. Dr. Flynn, as we get into this, what are some of the most common general concerns that parents may have around cardiac health for their kids? What do they tell you on a daily basis or what do they ask you?

Patrick Flynn, MD (Guest): Well first, thank you Melanie for having us because we’re glad to talk about these issues and to basically address the concerns of parents. I think that the main concern that parents have that revolve around cardiac health often have to do with either symptomatic issues that their toddler, child or adolescent have versus the concerns that might be voiced by a pediatrician at the time of a pediatric visit.

So, in terms of the symptomatic things, we will have parents bring their children to us for such complaints as chest pain, or palpitations or dizzy spells or fainting which we call syncope. And one of the things that we always like to point out from the very beginning is that at some point during childhood, and certainly during adolescence, those things are very, very common and very, very rarely do they point to a serious cardiac cause. In the younger children, in infants, it’s often a heart murmur or something else that the pediatrician picks up that they want us to check out and make sure that everything is okay. and in the vast majority of cases, even in those situations, you’re going to come through a pediatric cardiology visit and come out the other side pretty much the same way you came in.

Host: Well thank you for that and Dr. Bayle, as Dr. Flynn is telling us some of the common reasons that a pediatrician might refer an infant, child or teen to a cardiologist, and he mentioned a few; I think one of the most important questions that we’re gonna have really, is what are the symptoms. What are these things that might send up a red flag that would even bring a child to the pediatrician in the first place? Just chest pain? What else is going on?

Ken Bayle, DO (Guest):   You know one of the biggest things as cardiologists that we get concerned about is like you mentioned, chest pain and not just any type of chest pain but chest pain that’s associated with any type of physical activity, we get very concerned about. Because those are the ones that are typically associated with some cardiac finding. The other general cardiology complaints that we hear about that can be something that’s cardiac in origin are things like feeling your heart is beating rapidly, passing out, those are the few other things that we commonly see patients for that may have some cardiac etiology for their symptoms.

Host: But Dr. Bayle, don’t a lot of kids get chest pain and things? My son’s a gymnast and I know that sometimes you know, it could be gas and they can confuse it. How is a parent to know that it’s something that we worry about? I mean even adults worry about every time they get a little chest pain.

Dr. Bayle: Yes, that’s very true. It can be very confusing, and the picture can be very muddy but the good thing to know is like Dr. Flynn said, most of the chest pain in kids is not cardiac in etiology. The thing that we worry about the most though are the ones that are, can be very dangerous to patients. So, that’s why it’s important if you have any concerns at all, to speak to your pediatrician and have them refer them to a pediatric cardiologist if there is a high suspicion of some cardiac pathology going on.

Dr. Flynn: And I would also add on, there’s pretty much two scenarios of chest pain that, that give us some degree of yield in terms of finding heart problems. One as Dr. Bayle had mentioned is chest pain with exertion, again, when people are exerting themselves and have chest pain in the pediatric age group; it’s almost always the cause is either a muscle or bone pain or coming from the lungs. But in the small number of cases where it is coming from a cardiac situation, then those usually would be being provoked by exercise. As opposed to what we see a lot of is the child who comes in with episodes of sharp chest pain. I always think that when we ask patients where the pain is, one of the little clues I always have is, in almost any culture, if a person is having a heart attack, and again heart attacks in children and adolescents are extremely rare. But in any culture, if somebody’s having a heart attack, if you ask them where their pain is, they’ll do the same thing. They’ll make a fist. They’ll lean forward a little bit and they’ll put that fist right on the left side of their lower chest, right by the left breast. The minute I ask a child, or an adolescent where is the pain; and I see their finger come out, it almost doesn’t matter where their finger lands. That’s going to be something other than cardiac pain and it might be muscle or bone pain or it might be pulmonary – the minute they go, and they point to the location.

If the pain is reproducible like if they point to that location and I press on that area, and I say like that, and they wince; well that tells you right off the bat that it’s muscle or bone pain. But it’s the pain that comes with exertion that really needs to be checked out. And then the other type of pain is that the chest discomfort that’s been going on for a couple of days as opposed to most of the patients that we see that have been complaining of chest pain like that over a long period of time. If a person has a post viral illness, so after having a virus, they develop either inflammation around the heart which we call pericarditis or inflammation of the heart muscle itself which we call myocarditis. Those people will often complain of chest pain and it’s a constant pain that’s been going on for a couple of days. They might feel otherwise tired or have a malaise, a fatigue to them. They might have fever. They might also be feeling palpitations. So, those are the people that we’d rather be seen sooner than later cause they might have been healthy a week ago and be having an intercurrent problem or a more acute problem.

Host: Well I imagine as well that during COVID, this might have been a bit on the rise and we’re seeing more respiratory viruses as well. So, that probably contributes. Now Dr. Bayle, can you give us some general cardiovascular guidance that parents should know for their kids? You guys have given us great symptoms and reasons to go to the doctor and things that might alert parents. But some parents don’t know some general guidance. What’s important in terms of cardiovascular exercise? How much they should be doing? We hear about it for our adults, but it’s so important for our kids.

Dr. Bayle: Yes exercise for children is very important to keep their health good and keep their weight in the correct range. So, what we, as cardiologists generally recommend is 30-60 minutes of aerobic exercise and by aerobic exercise we mean the types of exercise where you’re getting your heartrate up. So things like running, swimming, biking. For the little kids even going around to the park and just letting them run around the playground is good cardiovascular exercise for them. And their efforts should be so that they’re sweating while they’re doing such activities. That’s how you know that their effort is good and they’re doing good cardiovascular exercise.

Host: And Dr. Flynn, along those lines, we have such a childhood obesity epidemic going on in this country. And that certainly contributes to heart issues and early heart issues including diabetes and hypertension. We’re seeing things in kids we never saw before. Speak just a little bit about diet and how that’s affecting our kids and the kinds of foods that you would rather see parents and the entire family try and work on eating and lifestyle modifications.

Dr. Flynn: It’s a timeless question and also a timely question. Because you’re right, a lot of the seeds of adult heart disease begin in childhood and adolescence with lifestyle issues. And that’s why it’s timeless but it’s also timely because we know that as a society, hopefully coming out now on the other end of the pandemic, we know that the nation and the world are in a different degree of fitness or conditioning than we all were two years ago. With the interruption of sports and so much time spent at home and the interruption of other activities. So, we’ve been actually acutely aware of this since the beginning of 2021, I think prompted by the American Heart Association looking at this as a not only a chronic problem in our society but an acute problem. We’ve actually had a very low threshold for referring people to our nutritionists for advice which has been very helpful because all of those are being done as video visits. And our patients have been giving us feedback not only are the visits more convenient because they’re video visits but they’re more valuable because it’s essentially as if the nutritionist has come into your home with you. You can just turn the phone or the laptop around, or the iPad around and go into the refrigerator and see what’s in there.

So, in general, we are in addition to the physical exertion and exercise that Dr. Bayle was mentioning; we just really want kids to have a balanced diet, to stay away from excessive sweeteners and fat content. And basically that so many kids will grow up and certainly go through adolescence devoid of a diet that contains fruits and vegetables in a manner that would be of good balance. And those are the things that we want to see people do and to keep that body mass index below the 85^th percentile which triggers us to be sending people for any type of professional advice on the subject.

Host: Well it’s certainly great advice to get kids and as you say even on a low threshold to nutrition counseling, working with a nutritionist or a dietician so that the whole family can learn together because it definitely when you tend to see an obese child, it also follows in some of the cases, many of the cases that the family is as well. So, that was really great advice Dr. Flynn. Now Dr. Bayle, kids are going to start spring sports and we’ve heard about things like sudden cardiac death. I mean there are cardiac issues with sports that we might not even really know our child might be at risk for. Are there things in the weather, change of seasons, as they start to play sports, I’d like you to just speak briefly about kids and sports and the risks and whether or not you think these pre-EKG as a part of their pre-participation sports physicals is something that you think is a good idea.

Dr. Bayle: You know there’s a lot of children and teenagers out there that are participating in these highly competitive sports especially through all seasons. But the weather change in particular doesn’t have anything particular, it’s not at any risk for any cardiac issues. You are right that there are a lot of parents out there concerned about sudden cardiac death as we hear numerous stories throughout the nations about kids all of the sudden dying, whether they’re high school students to college students to even the professionals. What we currently recommend for pre-participation screening is getting that evaluation done by your pediatrician and the most important things that they can do or ask about the family history, get a good physical exam and good history of any symptoms that may be cardiac related. And if they do all of these things, we can effectively screen any of these patients that may be at high risk for having sudden cardiac death and they can be sent over to us, to the pediatric cardiologist for further evaluation. And we can determine if they have any true cardiac disease that would preclude them from participating in any of the sports.

Dr. Flynn: And I would add Melanie that the question of pre-participation EKG screening is really a hot button topic because it all talks about cost benefit ratio and there are places in the world that routinely will screen athletes with EKG. Italy has been doing it for several decades and reportedly have decreased the risk of sudden cardiac death by almost ten-fold but that was also against the flurry of, of sudden cardiac deaths that they had over a period of time in the late 60s, early 70s, I believe that kind of triggered that.

There are places that at least places in other parts of the world I think do it a sensible way which is putting and EKG machine in the school and having the school nurse do them which is the key part of that cost part. In our society, if we recommended an EKG and that involved taking a day off of work, taking your child out of school, seeing a pediatric cardiologist for a consultation and getting that EKG plus all of the other testing that a pediatric cardiologist might tend to want to do in those situations, the cost would be prohibitive. But if we could find a way to do just the EKG and also most importantly, adhere to certain standards that have been developed for the screening of those EKGs. In other words that the EKGs are looked at for the signs of the conditions that can provoke sudden cardiac death in athletes. The official decision has been that it’s not cost effective to do that in our society but if we do those two things better, controlling the cost of the test itself, the secondary cost of work ups that are unnecessary after the test, we may change our mind on that in the not too distant future.

Host: Thanks for weighing in on that Dr. Flynn. What a great topic. I’d like to give you each a chance for a final thought. Dr. Bayle, starting with you, if a child does have cardiac issues, what is the latest on what we tell them about being involved in sports. I mean we’ve certainly changed the way we treat heart attacks in adults, getting them up the same day. What are we doing for kids that do have some cardiac issues as far as sports and school? Just give us a quick general return to play information for parents.

Dr. Bayle: So, for most patients, if not all patients, we do talk about exercise for those with and without heart conditions. For those with any type of heart condition, we will often advise them as to how much or what type of sports that they can participate in. Or for those that don’t qualify to participate, i.e. those that are at high risk for some complication like sudden cardiac death; we will often advise them against avoiding certain sports. So, there was a big meeting and there’s general guidelines for each type of heart condition that is out there, and we usually use those guidelines to base our decisions as to who can participate and what type of sport and how much they can exercise. But in general, for most kids who have heart disease, we are recommending some type of exercise, it just depends on how much they can do and what type of sports that they can participate in.

Dr. Flynn: And I would add I think that in the period of time that I’ve been doing this and I’m into my fourth decade now in pediatric cardiology so I’ve seen the field change a bit and I think one of the best places that’s changed is that 30 years ago, we spent a lot of time chasing our kids with congenital heart disease off of the basketball court and out of the pool and now I think we’re chasing them onto the soccer field, into the pool, into the gym, onto the dance floor because not only has our management of kids with congenital heart disease improved over the decades so that their cardiovascular status is a lot better than it was in previous generations of surgical repair; but I think we also have a lot more data and a lot more comfortable with that and I’d be remiss, you know we just finished another Olympiad, the last one that we’re able to point to Shawn White, the snowboarder who is exactly an example of that. He’s an individual who had fairly significant open heart surgery as a child, and it’s not a HIPAA violation. I’ve never taken care of Shawn White. I know all about this from what I’ve read in the paper and seen in NBC. Bu

But when he was a young child, undoubtedly, the recommendations from the American Heart Association for patients who had repair of Tetralogy of Fallot were to avoid competitive sports. and it never really made sense as a blanket recommendation. Nowadays, we would not be limiting people in that situation. The people that we limit are the patients with aortic aneurysms like patients with Marfan’s Syndrome, we don’t want them doing heavy collision sports or things that involve a lot of weight lifting. And the people that have some of those conditions that we’ve identified that are at risk for sudden cardiac death, hypertrophic cardiomyopathy, or certain arrythmias. But our patients that have had repair of open heart surgery, for the most part we expect them to live childhoods and adolescence and live well into adulthood just like everybody else. And we’re not imposing unnecessary restrictions on them anymore.

Host: Absolutely great information. Dr. Flynn, do you have any final thoughts, best advice, I’d like you to give parents about those symptoms, those scary little symptoms that kids get. They get so many. And what they really should be doing, thinking about, when it’s important to call their pediatrician.

Dr. Flynn: What you said at the end is really the most important thing, which is that if you have any questions whatsoever, talk to your pediatrician. Your pediatrician is your expert at knowing what is completely normal and what may require a workup and I will tell you Dr. Bayle, I’m sure will agree with me, we’ll see 40 or 50 kids with chest pain before we find one that has anything significantly wrong. But our feeling on that is that quite often the workup, since most of these things are either benign conditions or they’re something else, gastroesophageal reflux or a pulmonary thing; the concern is about heart disease and until we can take it off the table, it’s worse and it’s always a subconscious limitation to people.

So I often talk about when we do a workup of somebody with chest pain or palpitations or lightheadedness, it’s a diagnostic procedure, or a diagnostic workup that ends up being therapeutic as well. So, I would trust your pediatrician. The pediatrician knows that the great majority of people that they send for a cardiac evaluation are going to be normal and are going to just get reassurance, but they also know that we’re not going to find that unusual child that has a problem that could be difficult unless we have the opportunity to look for it.

The biggest group of worry are the parents of children and babies that are referred to us for heart murmurs that the pediatrician hears. And those would be signs of congenital heart disease and significant congenital heart lesions these days are generally picked up prenatally or in the newborn period so, if you bring me 100 four-year-olds, I’ll hear a heart murmur on 70 of them and less than one of them has anything wrong with their heart and we probably found that a long time ago. So, in that period of time, one of our biggest jobs is to allay the fears that any parent has and at the end of a pediatric cardiology visit, the parents should walk out completely comfortable that their child is well with the exception of those unusual cases where we do find something that needs some type of management or follow-up.

Host: What great information. Thank you gentlemen so much for joining us today and giving us encouraging information. Really kind of helping parents with those fears that we all have and laying it out so clearly for us. Thank you again. And Weill Cornell Medicine continues to see our patients in-person as well as through video visits and you can be confident of the safety of your appointments at Weill Cornell Medicine. That concludes today’s episode of Kids Health Cast. We’d like to invite our audience to download, subscribe, rate and review Kids Health Cast on Apple podcasts, Spotify and Google podcasts. For more health tips please visit weillcornell.org and you can search podcasts and don’t forget to check out our Back to Health. I’m Melanie Cole.

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