Furosemide Dosing for Pediatric Heart Failure
For children with heart failure, initiate furosemide at 1 mg/kg IV or oral dose, which can be increased by 1 mg/kg increments (no sooner than 2 hours after the previous dose) until adequate diuresis is achieved, with a maximum daily dose of 10 mg/kg/day. 1, 2
Initial Dosing Strategy
Start with 1 mg/kg given slowly IV (over 1-2 minutes) or orally as a single dose under close medical supervision. 2 This represents the standard FDA-approved initial dose for pediatric patients with heart failure. 2
Dose Titration Algorithm
- If diuretic response is inadequate after 2 hours: Increase by 1 mg/kg increments 2
- Frequency: Can be administered up to 6 times daily based on degree of edema and diuresis achieved 1
- Route considerations: IV administration is preferred in acute situations requiring rapid diuresis; oral therapy should replace parenteral therapy as soon as practical 2
Maximum Dosing and Safety Thresholds
The absolute maximum is 10 mg/kg/day for severe edema. 1 However, critical safety considerations apply:
- Doses exceeding 6 mg/kg/day should NOT be given for longer than 1 week due to significant ototoxicity risk 1
- For premature infants specifically, the maximum dose should not exceed 1 mg/kg/day 2
- IV infusions must be administered over 5-30 minutes to minimize ototoxicity risk 1
Clinical Context for Pediatric Heart Failure
The approach differs based on the underlying cardiac pathology identified on echocardiography:
Congenital Heart Disease with Left-to-Right Shunt
- Initial management with IV furosemide is appropriate 3
- Typically presents after the first few weeks of life 3
- Oxygen should generally be withheld due to pulmonary vasodilation and systemic vasoconstriction properties 3
Systemic Outflow Obstruction
- Furosemide should be used cautiously in conditions like hypoplastic left heart syndrome 3
- Prostaglandin E1 takes priority; oxygen is contraindicated 3
Dilated Cardiomyopathy/Decreased Ventricular Function
- Administer diuretics cautiously as acute preload reduction may cause hypotension 3
- Consider concomitant inotropic support (dobutamine, dopamine, epinephrine) 3
Administration Methods: Continuous vs. Intermittent
Continuous IV infusion offers advantages over intermittent boluses in postoperative pediatric cardiac patients: 4
- Produces same 24-hour urine volume with 21% less total drug requirement (4.90 vs. 6.23 mg/kg/day) 4
- Results in more controlled, predictable urine output with less variability 4
- Causes significantly less urinary sodium and chloride losses 4
- Continuous infusion protocol: Start 0.1 mg/kg IV bolus, then 0.1 mg/kg/hour infusion, doubling every 2 hours to maximum 0.4 mg/kg/hour if urine output <1 mL/kg/hour 4
Essential Monitoring Requirements
Regular monitoring must include: 1
- Fluid status and urine output
- Electrolytes (particularly potassium and sodium)
- Blood pressure
- Renal function (diuresis and estimated GFR)
- Symptoms and clinical status 3
Absolute Contraindications
Stop furosemide immediately if: 1
- Anuria develops
- Marked hypovolemia is present (could induce thrombosis)
- Poor peripheral perfusion without evidence of fluid overload
Maintenance Therapy Considerations
For chronic management after acute stabilization:
- Oral furosemide 2-5 mg/kg/day can be used for maintenance 3
- Consider combination therapy with thiazide or potassium-sparing diuretics for enhanced effect 3
- If potassium-sparing agents needed, amiloride is preferable to spironolactone 1
Common Pitfalls to Avoid
- Never exceed 6 mg/kg/day for more than 1 week - this is the most critical safety threshold for preventing permanent hearing loss 1
- Do not give IV furosemide rapidly - always administer over 1-2 minutes minimum to reduce ototoxicity 2
- Avoid in hypovolemic states - ensure adequate intravascular volume before initiating therapy 3
- Do not withhold oxygen universally - only in specific congenital lesions dependent on ductal flow 3