Paeds · clinical-pharmacology-and-therapeutics
Cardiovascular medicines in children
Also known as Paediatric cardiovascular drugs · Cardiac medications in children · Antihypertensives in children · Paediatric antiarrhythmics · Ductal and inotropic therapy in children
A fellowship approach to prescribing cardiovascular medicines in children, covering the diuretics, ACE inhibitors and beta-blockers used in heart failure, the inotropes digoxin and milrinone, the antiarrhythmics adenosine, amiodarone, flecainide and sotalol, the vasodilator antihypertensives amlodipine, labetalol, hydralazine and sodium nitroprusside, prostaglandin E1 for duct-dependent congenital heart disease, and the pulmonary vasodilators such as sildenafil — with weight-based doses, developmental pharmacokinetics, monitoring and the high-risk adverse effects that shape every prescription.
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Target exams
Red flags
- A neonate with a duct-dependent lesion who is not on prostaglandin E1, or whose infusion is running without a plan for apnoea, fever and hypotension
- Verapamil given to an infant with an undiagnosed broad or accessory-pathway tachycardia — it can cause cardiovascular collapse
- Digoxin continued in a child with hypokalaemia, renal impairment, or rising digoxin level and vomiting or bradycardia
- Sodium nitroprusside infused for a prolonged period without a cyanide-toxicity plan
- An ACE inhibitor started without a baseline and repeat urea, electrolytes and creatinine, particularly with a potassium-sparing diuretic
- Amiodarone continued long term without thyroid, liver, eye and QTc surveillance
- A cardiovascular drug prescribed without a current weight, or with a tenfold or decimal-point dose error
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Current 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young person
- Current 2026 PREP curriculum — Learning Objective: Safe prescribing and medication management in infants, children and young people
- Current 2026 PREP curriculum — Learning Objective: Understand the pharmacological management of cardiac, circulatory and haemodynamic disorders
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 9: Quality and safety, including medication safety
- Clinical Applications
- Medical Sciences
- Long Cases
- Short Cases
- 4. Professional skills and knowledge: Patient management
- 7. Patient safety, including safe prescribing
- 8. Quality improvement and patient safety
- Cardiology: Recognises, resuscitates and stabilises the acutely unwell cardiac patient, including duct-dependent disease and arrhythmia
- General Paediatrics: Prescribes and monitors cardiovascular medicines safely using weight-based dosing
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- General Pediatrics Content Outline — Domain 10: Principles of Pharmacology and Medication Management
- General Pediatrics Content Outline — Domain 6: Cardiology
- General Pediatrics Content Outline — Universal Task 4: Management and Treatment
- Systems-Based Practice 1: Patient Safety and Quality Improvement
- Patient Safety/Quality Improvement 1: Medication Safety
- Medical Knowledge 2: Diagnostic and Therapeutic Decision Making
- Medical Expert
- Pharmacist
- Pediatrics: Core EPA #5 — Recommending and Initiating Pharmacologic Interventions
Overview & Definition
Picture a two-month-old turning grey on the postnatal ward, a five-year-old with a racing narrow-complex tachycardia, and a teenager in the emergency department with a blood pressure of 180 over 110. Each child needs a cardiovascular medicine, and in each case the medicine is powerful enough to rescue or to harm. The discipline of prescribing these drugs in childhood is built on one idea: the dose is matched to the child's weight and developmental physiology, and then watched for effect drug is meant to produce and the harm it is capable of causing. [1] [4]
A cardiovascular medicine in paediatric practice is any drug whose primary action is on the heart, the circulation, or the vascular tone. That includes the drugs used for heart failure, arrhythmia, hypertension, duct-dependent congenital heart disease and pulmonary hypertension. What sets these drugs apart is how narrow the gap is between the dose that helps and the dose that harms, and how much that gap moves with age. A neonate clears digoxin slowly and tolerates prostaglandin E1 apnoea; a school-age child clears a beta-blocker faster than an adult per kilogram; a teenager on an ACE inhibitor needs pregnancy counselling. The same mg-per-kilogram dose is never assumed to behave the same way at two ages. [1]
From the prescription to a safe, on-target cardiovascular drug
- 1
1 · Confirm the current weight
Weigh the child and recheck at intervals; every cardiovascular dose is calculated per kilogram against a current weight.
- 2
2 · Correct for age and organs
Adjust for developmental clearance (neonate, infant, adolescent) and for renal or hepatic function before the first dose.
- 3
3 · Give the loading or starting dose
Start low where the drug is high-risk (ACE inhibitor, beta-blocker, vasodilator); load where a rapid effect is needed (adenosine, digoxin, prostaglandin E1).
- 4
4 · Monitor the effect and the harm
Watch the heart rate, blood pressure, saturation, QTc, renal function and potassium, and the drug level where indicated.
- 5
5 · Titrate and review
Up-titrate over days to weeks for chronic drugs; set a stop or wean date for high-risk acute drugs; review interactions at every change.
References11ShowHide
- [1]Kearns GL, Abdel-Rahman SM, Alander SW, Blowey DL Developmental pharmacology--drug disposition, action, and therapy in infants and children. The New England journal of medicine, 2003.PMID 13679531
- [2]Shaddy RE, Boucek MM, Hsu DT, Boucek RJ Carvedilol for children and adolescents with heart failure: a randomized controlled trial. JAMA, 2007.PMID 17848651
- [3]Hsu DT, Zak V, Mahony L, Sleeper LA Enalapril in infants with single ventricle: results of a multicenter randomized trial. Circulation, 2010.PMID 20625111
- [4]Hsu DT, Pearson GD Heart failure in children: part II: diagnosis, treatment, and future directions. Circulation Heart failure, 2009.PMID 19808380
- [5]Loss KL, Shaddy RE, Kantor PF Recent and Upcoming Drug Therapies for Pediatric Heart Failure. Frontiers in pediatrics, 2021.PMID 34858897
- [6]Hoffman TM, Wernovsky G, Atz AM, Kulik TJ Efficacy and safety of milrinone in preventing low cardiac output syndrome in infants and children after corrective surgery for congenital heart disease. Circulation, 2003.PMID 12600913
- [7]Batra AS, Silka MJ, Borquez A, Cuneo B Pharmacological Management of Cardiac Arrhythmias in the Fetal and Neonatal Periods: A Scientific Statement From the American Heart Association: Endorsed by the Pediatric and Congenital Electrophysiology Society (PACES). Circulation, 2024.PMID 38314551
- [8]Ruopp NF, Cockrill BA Diagnosis and Treatment of Pulmonary Arterial Hypertension: A Review. JAMA, 2022.PMID 35412560
- [9]Berman Rosenzweig E, Barst RJ Pulmonary arterial hypertension : a comprehensive review of pharmacological treatment. Treatments in respiratory medicine, 2006.PMID 16512692
- [10]Taksande A, Jameel PZ Critical Congenital Heart Disease in Neonates: A Review Article. Current pediatric reviews, 2021.PMID 33605861
- [11]Eades SK, Christensen ML The clinical pharmacology of loop diuretics in the pediatric patient. Pediatric nephrology (Berlin, Germany), 1998.PMID 9761364