Cardiology: Then and Now

20130424_1668February is national heart month, so I thought there was no better time than now to visit my friends at CHOC Children’s Heart Institute.

So much has changed in the field of pediatric cardiology since I first visited CHOC in 1964. From diagnosis to treatment, the Institute today cares for children of all ages with a spectrum of cardiac conditions. The Institute offers a host of services, ranging from surgery to cardiac catheterization to interventional cardiology.

The Institute also offers expert diagnostics for diagnosing complicated heart issues – the first step in helping a child feel better. Here’s just a snapshot of CHOC’s many diagnostic offerings:

  • Electrocardiogram (EKG), Holter monitoring and cardiac event monitor recording
  • Pediatric ergometer and treadmill stress-testing
  • Fetal echocardiography and prenatal cardiac diagnosis
  • 2D and 3D real-time resting, stress and sedated echocardiography
  • 1.5T and 3.0T magnetic resonance (MRI) and CT angiography with 3-D image reconstruction
  • Diagnostic cardiac catheterization and therapeutic cardiac catheterization in state-of-the-art catheterization laboratories

I love CHOC heart patients, and I’m so grateful for the cardiologists, nurses and other staff who help care for them. How has CHOC helped your heart — besides filling it with joy? Let me know on social media by using the hashtag #thxCHOC.


The CHOC Children’s Heart Institute offers state-of-the-art diagnosis and treatment for an entire spectrum of cardiac conditions all in one convenient, family friendly location. Moreover, it is the only pediatric-dedicated facility in Southern California offering the latest in advanced cardiac care, and is the only regional facility to perform neonatal and pediatric open heart surgery. CHOC has assembled a multi-disciplinary team, specially trained in the management of infants and children with congenital heart defects.


Kids and Healthy Hearts



kidsandheartsRISK FACTORS
Children who don’t have heart problems as kids may develop them as adults, due to risk factors like obesity and hereditary factors, says Dr. Linda E. Muhonen, a pediatric cardiologist at CHOC Children’s. Risk factors that contribute to coronary artery disease and other cardiovascular diseases include smoking, poor diet that can lead to  dyslipidemias, high blood pressure and a lack of exercise. These often take root at an early age. “An obese child has an 80 percent chance of being an obese adult, and obesity can contribute to the onset of multiple illnesses including diabetes and hypertension,” says Dr. Muhonen.

“Parents should avoid bringing unhealthy foods into the home, such as soda or sugar-sweetened drinks,” says Dr. Muhonen. “The only drinks most kids should have are water and fat-free milk. Kids should eat three meals a day with snacks of fruits and vegetables in between. Many children skip meals, creating an environment of overeating at  the next meal; skipping meals can lead to lowering your metabolic rate. We encourage children to bring their lunch to school so they can pack something healthy like a turkey sandwich on whole wheat bread, a piece of fruit and some pretzels or string cheese.”

“I like to see families have some healthy family time before dinner, like going for a family walk or going to the park before they sit down to eat,” says Dr. Muhonen. “This gets the kids to move. One of the rules in our Lipid Clinic, where we help kids at risk for developing heart disease, is that children cannot watch TV or have screen time until they have been outside for an hour doing a physical activity. The American Heart Association recommends that children have an hour a day of moderate to vigorous physical activity. It doesn’t have to be all at one time,” she says.

Children are considered overweight if their Body Mass Index (BMI) falls in the 85-94th percentile. They are considered obese if their BMI falls in the 95th percentile or above, says Dr. Muhonen. Parents can ask their  pediatrician to help make this determination.


  • Approximate number of children ages 12-17 who are already smokers: 4.5 Million
  • Percentage of obese children who will become obese adults: 80%
  • Approximate percentage of children and adolescents (ages 6-19) who were overweight or obese in 2010: 33%

View the full feature on Kids and Healthy Hearts

Dr. Linda Muhonen


Dr. Muhonen helps patients with the full spectrum of heart conditions, with special emphasis in preventive cardiology. She also directs the Children’s Cholesterol (Lipid) Clinic at CHOC. Dr. Muhonen served her Pediatric Cardiology fellowship at the University of Iowa Hospital in Iowa City and she completed her internship and residency at Loma Linda University Medical Center. Part of her practice focuses on helping children avoid heart problems related to genetics and/or obesity later in life. She is the leading physician at CHOC’s Lipid Clinic, which treats these “at risk” children.

Dr. Muhonen’s philosophy of care: “I focus on the family as a whole when treating children with heart and obesity related problems. You can’t just focus on the child because a child is a product of genetics and their environment.”

Oral Roberts School of Medicine – Tulsa, Oklahoma

Pediatric Cardiology

More about Dr. Muhonen | More about The Heart Institute at CHOC Children’s

This article was featured in the Orange County Register on February 17, 2014 and was written by Amy Bentley.

Exercise for Healing Hearts

Parents of children with congenital or acquired heart conditions who have been cleared to exercise are often concerned about safety. And this concern is justified because strenuous physical activities, such as running and soccer, may not be the safest choices for a child with a heart condition.

However, “low-activity” physical exercis20130425_3047e may be part of the prescription, says Dr. Anthony Chang, medical director of the CHOC Children’s Heart Institute.

Exercise is a crucial component of protecting against obesity, and even children with heart conditions are not immune to this problem. Luckily, many less-strenuous activities deliver the health benefits without involving sudden increases in heart rate and blood pressure.

“Physical activity is an important part of a healthy lifestyle, and many children with heart conditions may exercise safely,” Dr. Chang says. “Additionally, exercise can be an important diagnostic tool to monitor how well the child is doing. If a child cannot exercise as much or starts showing symptoms, this may indicate the heart is not doing as well.”

Additionally, these less-intense exercises include several that the entire family may enjoy doing together. Several activities are often recommended for patients who have been cleared for exercise:

• Walking

• Swimming

• Yoga

• Golf

Exercise Caution

Every child’s heart is different. Pediatric cardiologists and pediatricians use several types of tests and assessments before clearing a patient for exercise, including an electrocardiogram (EKG), echocardiogram and, in children older than age 7, exercise stress testing.

Once a child is cleared for exercise, parental or adult supervision is highly recommended. Ideally, there should be someone there who is trained to perform CPR and can operate an automated external defibrillator (AED) should the need arise.

A child should immediately stop an activity if the following symptoms occur:

• Chest pain

• Dizziness

• Unusual fatigue

“It is always a good idea to have someone there who is trained to perform CPR and use an AED,” Dr. Chang says. “That’s not just for the child with the heart condition, but for everyone. No one can predict who will experience sudden cardiac arrest.”

Learn more about CHOC Children’s Heart Institute.

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A Healthy Heart Starts Early

Did you know the seeds for a healthy heart in adulthood are often planted during childhood? Children with poor diets and inadequate exercise can develop a range of heart-related diseases later in life.

Parents and other caregivers can set children on a path to a healthy heart, says Dr. Linda Muhonen, a pediatric cardiologist at CHOC Ch20130426_0625ildren’s who also leads CHOC’s Lipid Clinic. (“Lipid” is a general term for molecules in the body that include fat.) Often, this means a permanent lifestyle change for families.

“For kids to have a healthy heart during their lives, families have to lead more healthy lifestyles from the start,” Dr. Muhonen says. Parents should model heart-healthy habits to their children. Prevention is the best way to avoid heart problems later in life.”

Dr. Muhonen and the Lipid Clinic staff help children with genetic dyslipidemias or who are overweight or obese lower their risk for developing heart disease and related illnesses such as asthma or diabetes. They study the patient’s history, examine the child, prescribe medication if necessary and set up new dietary and exercise goals for kids and families with the help of a dietitian and exercise physiologist , she says.

“The bottom line is that our kids are developing diabetes in early adolescence,” Dr. Muhonen says. “Kids can also develop asthma, hypertension and fat in the liver, which can lead to chronic liver disease all related to obesity. You can help prevent these illnesses by not having a sedentary lifestyle and not becoming obese.”

Dr. Muhonen offers some dietary and exercise tips for parents to establish heart-healthy habits for their children:

  • Avoid soda, juice and other sugar-sweetened drinks; offer the kids fat-free milk at meals and water the rest of the day. “You should avoid drinking your calories,” Dr. Muhonen says.
  •  Children should eat three meals a day with snacks of fruits and vegetables in between.
  • Don’t let the children skip meals. Skipping meals can lead them to overeat at the next meal and can slow down your metabolism.
  • Have kids take their lunch to school instead of buying lunch. Pack a heart-healthy lunch such as a tuna or turkey sandwich on whole wheat bread with a piece of fruit and some pretzels or string cheese, and a bottle of water.
  • Never reward children with food. Encourage kids to get an hour of physical activity each day. This can be whatever activity or sport interests the child. “You don’t need a gym membership or equipment to get some exercise,” she says.
  • Warn children about the dangers of cigarette smoking and encourage them never to start

More articles about healthy eating habits:

  • 5 Ways to Reduce Intake of Food Additives
    What exactly are food additives anyway, and how can you help your family avoid them? A CHOC registered dietitian explains.
  • Healthy Eating Tips for the School Year
    It’s time to head back to school, and with that comes a fresh opportunity to establish new habits with children and teens. As your family falls into a routine around ...
  • Overcoming the Struggles of Picky Eating
    Picky eating is very normal for children, particularly in toddlers who have a natural fear of new foods. In fact, research shows that most kids get appropriate nutrition regardless of ...

How ECMO Can Save a Child’s Life

DomicoBy Dr. Michele Domico, medical director, CHOC Children’s ECMO service

Children who are hospitalized with critical cardiac or pulmonary disease and don’t respond to current medical treatments might be candidates for a life-saving device called extracorporeal membrane oxygenation (ECMO).

ECMO (also known as extracorporeal life support) is a heart and lung bypass machine that can be used to rest a failing heart or lungs, providing complete support for a few days, or even weeks, until the heart and lungs recover.

A physician from CHOC Children’s ECMO team can evaluate a child to see if he or she is a candidate for this specialized treatment. ECMO is not offered to every patient because it is a high-risk procedure with possible complications. However, ECMO has saved many children’s lives when all else failed.

CHOC was one of the first centers to use this life-saving device, to saving a newborn infant dying from lung disease in 1975. Since then, ECMO has become widely used for infants and children with certain life threatening lung or heart problems. CHOC remains today the only hospital in Orange County to provide this complex life-saving treatment.

ECMO is most often used for children born with congenital heart defects, post-surgical patients and children with severe pneumonia. In 2012, CHOC published a practice-changing study that suggested expanding the use of ECMO for patients with severe lung disease or pneumonia who were previously not considered ECMO candidates.

More broadly, the CHOC ECMO program has made great strides in recent years, with state-of-the art equipment, an increased number of patients, excellent outcomes and improved ECMO specialist training.

The platinum-level Extracorporeal Life Support Organization (ELSO) Award of Excellence in Life Support recognizes programs worldwide that distinguish themselves by having evidence-based processes, procedures and systems in place that promote excellence in ECLS. As a recipient of a platinum designation, CHOC is among the highest scoring institutions.

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