Recurrent Respiratory Tract Infections in Young Infants? An Alert to Investigate for CHDs!

Recurrent respiratory tract infections (RRTIs) represent a widespread childhood medical condition that pose significant challenges to pediatric healthcare providers. The CHDs increase the risk of frequent upper respiratory tract infections (URTIs) in infants under 5-6 months, due to compromised respiratory and cardiovascular systems. Recurrent or Frequent respiratory upper tract infections (RRTIs/ FRUTIs) trigger medical consultations and emergency room visits, significantly impacting the well-being of affected Infants and Children. Among the leading conditions, Heart’s valvular defects are known to lead to inefficient blood flow and increase the risk of respiratory complications, and the severity of the CHD plays a role.  While majority of children with CHD have mild respiratory symptoms only, but a few may present with Cyanosis, breathlessness and feeding difficulties. early diagnosis and management of CHD not only help reduce the risk of respiratory complications but also improve overall outcomes. Advances in pediatric cardiology & cardiac surgery have made it possible to repair or palliate most of the CHDs. With improving access to screening, early diagnosis & treatment, over 90% of newborns with CHD have good long-term outcome now!

This article is an outcome of the author following two cases of recurrent Respiratory Infections leading to a diagnosis of CHD; one boy now aged about 3.5 years born with Tetralogy of Fallot and a girl born with Peri membranous VSD with Left to right shunt both identified at an age of 2 weeks and 2 months respectively. While in the first case a boy underwent an Intra-cardiac repair with a short transannular pericardial patch on 17 January 2023, has been progressing well with near normal growth and development. The girl’s VSD closed spontaneously at her 10 months age, and the girl is happily celebrating her first birthday on 17 August 2025.

Recurrent or Frequent respiratory tract infections (RRTIs/ FURTIs) trigger medical consultations and emergency room visits, significantly impacting the well-being of affected Infants & Children. One common reason for RRTIs is congenital cardiac/heart diseases (CHDs) in infants under 5-6 months, due to compromised respiratory and cardiovascular systems. Congenital heart diseases (CHDs) are the most common birth defects, responsible for nearly one-third of all congenital birth defects [1]. The birth prevalence of CHD is reported to be 8-12/1000 live births globally [2,3]. One-fifth (20%) of these babies have critical heart disease requiring early intervention. Advances in pediatric cardiology & cardiac surgery have made it possible to repair or palliate most of the CHDs. With improving access to screening, early diagnosis & treatment, over 90% of newborns with CHD have good long-term outcome now [4]. Considering at birth prevalence of CHDs as 1%, the estimated number of children born with CHD every year in India approximates 250,000, posing a tremendous challenge for the families, society, and health-care system. CHDs account to 10% of infant mortality in India [6].

CHD affects the heart's ability to pump blood effectively, leading to increased pressure in the lungs and potentially causing respiratory distress and making it harder for the infant to clear respiratory secretions and fight off infections. Some CHD can also impair the immune system, making infants more vulnerable to infections, including URTIs. Even minor URTIs are often more severe in infants with CHD, potentially leading to complications like bronchiolitis or pneumonia. Infants with congestive heart failure, cyanosis, or pulmonary hypertension are particularly at risk for severe respiratory infections due to compromised cardiac function & oxygen delivery. Among the leading conditions, Heart’s valvular defects are known to lead to inefficient blood flow and increase the risk of respiratory complications. The severity of the CHD plays a role in the likelihood and severity of URTIs with more complex defects posing a greater risk. Though most such infants have mild respiratory symptoms, one third of infants with CHD experience frequent URTIs.  Early diagnosis and management of CHD not only help reduce the risk of respiratory complications but also improve overall growth and development [5]. This article is based on two cases of recurrent Respiratory Infections leading to a diagnosis of CHD; one boy now aged about 3.5 years now, born with Tetralogy of Fallot and a girl few weeks short of first birthday, born with Peri membranous VSD with Left to right shunt. Both were identified early at an age of 2 weeks and 2 months respectively. While the first needed surgical intervention and has been progressing well with near normal growth and development. The girl’s VSD closed spontaneously for 10 months, and the girl is happily celebrating her first birthday on 17 August 2025.

A case of Tetralogy of Fallot: Shruti an young Ayurvedic doctor and MPH scholar delivered a normal male child on 22 March 2022. Antenatal check-up including 2-3 scans (first on 20 November 2021 at 21 weeks of pregnancy) had not indicated any fetal structural abnormalities. However, on 6 April 2022, Samarth, a 15-day old baby was taken to a pediatric cardiologist for Cyanosis, breathing & feeding problems. The cyanosis associated was due to right-to-left shunting of de-oxygenated blood at the level of the VSD. Cyanosis was progressive and life-limiting; he used to squat down, to increase pulmonary blood flow. Basic investigations of i) pulse oximetry ii) echocardiogram iii) ECG and iv) Chest Xray were done. The echocardiography showed Large Mal-aligned VSD BD Shunt with Severe Pulmonary Stenosis but with good Biventricular Function. Tricuspid, Mitral and Aortic Valves were normal. Pulmonary valve had severe sub valvular Pulmonary Stenosis grade 68mm Hg. EF was 60%, FS=35%, LVDd=16mm, LVSd=14mm, LVPwD=4mm. Local pediatrician managed frequent episodes of Cyanosis and respiratory distress with symptomatic medical treatments until the baby was 10 months old and advised surgical corrections thereafter. The boy was admitted on 09 January 2023 to Narayana Heart center a dedicated cardiac Hospital. On admission the condition was noted as: Admitted with a diagnosis of tetralogy of Fallot, with confluent good sized pulmonary arteries; S/P RVOT stent. An Intra-cardiac repair with short transannular pericardial patch on 17 January 2023. His immediate post operative period was uneventful and drained less. He was extubated on 1st Post Operative Day and discharged on 25 January 2023 in stable condition. Parents were advised to get the child back if they notice any chest pain, breathing difficulty, Palpitations, low urine output or bleeding from any place. Annual scanning is being done to monitor the condition. Since then, boys’ growth & development are fine and now, the 3.5-year-old boy is cheerful.

Mild VSD Closing Spontaneously:  Vanshika, a female precious infant born on 17 August 2024, following three years of fertility follow-up of her parents married in 2021 facing primary sterility issue with follicular studies, & other investigations. She had the first URTI on 25th October 2024, exhibiting hurried breathing, and vomiting when she was 9 weeks old. After 3-4 days of home remedies, she was taken to a private pediatric hospital. After symptomatic management for 2 days in intensive care unit, a 2D Echo on 3 November revealed Peri membranous VSD with Left to Right shunt. Local pediatricians feared that it could lead to congestive heart failure (CHF) and started medical management of RRTIs. Chest Xray on 30 October 2024 was normal, but A 2 D echo on 3 November 2024 by pediatric cardiologist from Bengaluru confirmed her as a case of PM VSD (1.5m) & L-R Shunt. While repeated RTIs were managed repeat 2 D Echo in March 2025 confirmed that VSD had closed spontaneously. Her RTIs have drastically decreased since April 2025 and the girl’s growth and developments are near normal for the age.

Children with congenital heart disease (CHD) are at an increased risk of developing repeated respiratory infections due to the way their heart defects affect their lungs and immune systems. These infections, particularly lower respiratory tract infections (LRTIs), are more severe in, leading to increased hospitalizations and potentially contributing to further complications [2,3].

Pathophysiology: Congenital heart defects cause hemodynamic disturbances in the lungs, leading to increased blood flow or pressure in the pulmonary circulation, & predispose infants to infections. Some heart defects affect lung function, making lungs expansion and contraction difficult, increasing susceptibility to infections. CHDs also affect the immune system, reducing infants’ ability to fight off infections. In some cases, CHD if not treated in time, leads to (CCF) congestive heart failure, making the kids more vulnerable to infections. Some Children with CHD develop severe LRTIs like pneumonia, requiring hospitalization and in severe Cyanotic CCDs may need surgical corrections at a young age [3].

Common symptoms of LRTIs in children with CHD include coughing, reduced feeding, fever, runny nose, and wheezing. Some children experience cyanosis due to low oxygen levels. Sometimes symptoms appear later in life or return years after treatments.

Therefore, it is crucial to identify children with CHD early on, by screening children with recurrent LRTIs. Managing CHD effectively helps to reduce the risk & severity of respiratory infections and allows the normal growth and development of the infants [2,3].

Magnitude of the Problem: The prevalence rates of congenital heart disease at birth changed little temporally, resulting in about 12 million people living with CHDs globally, an 18·7% increase from 1990 to 2017, and causing a total of 590,000 years lived with disability. CHDs caused about 261 247 deaths globally in 2017, a 34·5

With India birth rate for 2025 as 16.55 /1000 people, we would have about 25 million births in 2025. Considering a birth prevalence as 10/1000 births, the estimated number of children born with CHD in 2025 in India approximates 250,000, posing a tremendous challenge for the families, society, and health-care system.

Every health care worker, pediatrician/cardiologist/ must strive to get a complete diagnosis on a child suspected of having heart disease, with the help of a higher center, if needed.

While the national guidelines are applicable to the majority, each case needs individualized care, and exceptions may have to be made based on clinical judgment.

In initial medical management Oxygen saturations are monitored closely to determine physiological condition and guide timing of intervention. If Pulmonary Stenosis is minimal, and presence of symptoms of pulmonary over circulation is an indication for medical therapy, delaying the surgical intervention as long as possible till baby is 6-10 months old.

Abbreviations

CHD= congenital heart diseases

FURTI/RRTI= Frequent upper respiratory tract infections/ Repeated respiratory tract infections

VSD= Ventricular Septal defect

ASD= Atrial septal defects

PDA= Patent ductus arteriosus

MVP= mitral valve prolapses

CYCD= Cyanotic Cardiac diseases 

ACYCD= Acyanotic CCDs,

CCF= congestive cardiac failure