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Challenges in Medication Titration in Children with Heart Failure

Challenges in Medication Titration in Children with Heart Failure 1024 537 Pam Georgiana

Beyond the guidelines: implementing consensus-based care for complex patients.

Pediatric heart failure is a complex clinical diagnosis, with a growing body of evidence to suggest there are critical differences between pediatric and adult heart failure. In a recent review published in JHLT Open, Jessie Yester, MD, PhD and Deipanjan Nandi, MD highlight the unique challenges of medication titration in children and the need for pediatric-specific strategies, collaborative care and ongoing research.

Pediatric vs. Adult Heart Failure

Although pediatric heart failure is less prevalent than adult heart failure, the per-patient burden is higher. Children with heart failure experience greater morbidity and mortality. They also require more resource utilization.

There is also greater heterogeneity of heart failure etiologies in pediatrics, which makes studying treatment strategies challenging. Current prescribing practices are primarily based on adult guideline-directed medical therapy. However, these medications may not be as effective for pediatric patients.

“Our adult heart failure colleagues have developed different treatment strategies based on heart failure subtypes. We need to do the same in pediatrics,” Dr. Yester, a pediatric heart failure and transplant specialist at Nationwide Children’s Hospital, explains, “By identifying the subtypes, we can develop more specific approaches to their management.”

Managing heart failure with oral medications is an essential therapy for children. However, titrating young, growing patients to the right dose can be daunting.

Challenges in Medication Management

The review identifies four main barriers to effective pediatric titration:

  • Prescriber reluctance: Without robust pediatric data, clinicians may be hesitant to start or advance therapy.
  • Patient and family factors: Concerns about prescribing multiple medications and potential side effects are common, particularly given the fragile status of this population.
  • Formulation and dosing limitations: Weight-based dosing, liquid suspensions with short shelf lives, and a lack of child-friendly formulations complicate care.
  • System and workforce barriers: Insurance denials, pharmacy access, limited reimbursement for frequent monitoring, and the need for dedicated pediatric heart failure teams hinder consistent titration.

“Even when we know that medications might help, the lack of access and guidelines can be enormous barriers,” notes Dr. Yester. “Families are understandably cautious about these very real concerns.”

Practical Considerations for Providers

In response to this review, Dr. Yester recommends several strategies to support optimal prescribing in pediatric patients with heart failure.

Focus on Function

Pediatric patients often present with lower blood pressure, which may limit traditional dosing strategies. Providers should focus on patient symptoms, medication tolerance, and overall function rather than strictly adhering to numeric targets.

Partner with Specialists

Local cardiologists and pediatricians play a vital role, but collaboration with specialized programs, such as Nationwide Children’s Heart Center, ensures access to the latest protocols and expert support.

Use Available Resources

Networks such as ACTION (Advanced Cardiac Therapies Improving Outcomes Network) have created consensus treatment documents, discharge tools and pocket references with dosing and lab schedules to support community providers.

Expect Variability

Children have a greater potential for myocardial recovery than adults, meaning some may improve on lower doses, while others require complex multi-drug regimens. Some patients respond quickly, while others do not tolerate standard regimens. Individualized titration, with close monitoring, is critical.

The Role of Collaboration

Pediatric heart failure care is the “ultimate team sport,” says Dr. Yester. Physicians, nurses, pharmacists, advanced practice providers, community advocates and families must work together to provide the best care. Beyond the bedside, national and international collaboration through registries, quality initiatives, and multicenter trials is necessary to establish a similar evidence base to that for adult care.

“We cannot practice this type of medicine in isolation,” Dr. Yester says. “We need coordinated provider teams with real-world knowledge and a collaborative effort to harmonize care.”

Looking Ahead

Pediatric heart failure care demands creative solutions in medication and other treatment options. Dr. Yester emphasizes the urgent need for more formulations for children, innovative delivery methods and rigorous clinical trials. Until then, providers must use consensus guidelines, quality improvement networks and clinical judgment to achieve the best outcomes.

“By leaning on real-world insights from collaborative networks and advancing our understanding of pediatric-specific heart failure mechanisms, we can begin to bridge the evidence gap and improve outcomes for children living with heart failure through more targeted treatment strategies,” Dr. Yester concludes.

 

Reference:

Yester J, Nandi D. Challenges in medication titration in children with heart failure. JHLT Open. 2025;10:100358. Published 2025 Aug 5. doi:10.1016/j.jhlto.2025.100358

About the author

Pam Georgiana is a brand marketing professional and writer located in Bexley, Ohio. She believes that words bind us together as humans and that the best stories remind us of our humanity. She specialized in telling engaging stories for healthcare, B2B services, and nonprofits using classic storytelling techniques. Pam has earned an MBA in Marketing from Capital University in Columbus, Ohio.

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