Modified Ross Score for Infants and Young Children With Heart Failure
The Modified Ross classification is a clinical severity score used to grade heart failure in pediatric patients using age-appropriate symptoms and signs. [1]
Infant Scoring Method
For infants, severity is scored from multiple clinical items. [1]
Items assessed in the Ross scoring system for infants are each graded (0–2). [1]
- Feeding history (scored 0–2). [1]
- Time taken per feeding (scored 0–2). [1]
- Respiratory rate (scored 0–2). [1]
- Respiratory pattern (scored 0–2). [1]
- Peripheral perfusion (scored 0–2). [1]
- Third heart sound/diastolic rumble (scored 0–2). [1]
- Liver edge/hepatomegaly (scored 0–2). [1]
The total score is interpreted as follows. [1]
- 0–2: no heart failure. [1]
- 3–6: mild heart failure. [1]
- 7–9: moderate heart failure. [1]
- 10–12: severe heart failure. [1]
Clinical Description Corresponding to the Ross Categories (Infants)
The Modified Ross descriptors that correspond to infant severity categories are summarized below. [1]
- Mild (typically ≤6): mild tachypnea or diaphoresis with feeding. [1]
- Moderate (typically 7–9): growth failure with marked tachypnea or diaphoresis with feedings. [1]
- Severe (typically ≥10): symptoms at rest such as tachypnea, chest retractions, grunting, or diaphoresis. [1]
Management for Mild Heart Failure (≤6)
Mild congestive heart failure is managed on an outpatient basis in stable patients. [1]
Chronic management steps for mild heart failure include the following. [1]
- Initiation of an ACE inhibitor as the cornerstone of treatment in pediatric congestive heart failure associated with CHD, myocarditis, or dilated cardiomyopathy. [1]
- Use of low-dose loop diuretic (frusemide) at 1 mg/kg/day. [1]
- Addition of an inotrope (digoxin) or a beta-blocker (carvedilol) for mild CHF. [1]
Management for Moderate Heart Failure (7–9)
Moderate congestive heart failure is managed on an outpatient basis in stable patients. [1]
Chronic management steps for moderate heart failure include the following. [1]
- Increase of frusemide to 2 mg/kg/day. [1]
- Addition of a second diuretic agent such as hydrochlorothiazide (HCT) or metolazone. [1]
- Simultaneous addition of HCT or metolazone to frusemide for synergistic diuretic effect. [1]
- Addition of spironolactone or eplerenone to attenuate diuretic-induced hypokalemia. [1]
Management for Severe Heart Failure (≥10)
Severe congestive heart failure is treated with the moderate-to-severe chronic management pathway described for CHF in stable patients. [1]
Chronic management steps applied to severe heart failure include the following. [1]
- Increase of frusemide to 2 mg/kg/day. [1]
- Addition of a second diuretic agent such as hydrochlorothiazide (HCT) or metolazone. [1]
- Simultaneous addition of HCT or metolazone to frusemide for synergistic effect. [1]
- Addition of spironolactone or eplerenone to attenuate diuretic-induced hypokalemia. [1]
- Consideration of beta-blockers such as metoprolol or carvedilol for chronic congestion. [1]
Acute Severe Disease Supportive Measures Referenced With Pediatric Heart Failure
For hospitalized infants with heart failure, supportive measures include daily weighing if admitted. [1]
- Supplemental oxygen is recommended in severe cases. [1]
For older children presenting with acute decompensated heart failure, initial management includes admission, evaluation for congenital heart disease, and empiric diuresis for congestion with IV frusemide. [1]
In cases with significant hypotension in acute decompensation, dopamine infusion 5–10 mcg/kg/minute and/or milrinone 0.3–1 mcg/kg/minute is referenced. [1]