An invisible scourge is haunting India, its dark shadow already beginning to the spread across the most vulnerable of all: children. And the menace is childhood heart disease. One in every 100 babies, or an estimated 2,00,000-2,40,000 children are born with Congenital Heart Disease (CHD) in India each year. Around one-fifth are estimated to have serious defects requiring intervention in the first year of life. An estimated 3.5 million adults are also living with CHD in the country.
But all is not bleak, though the contrast is disheartening. There is Tejbir Singh: a vibrant, energetic two-and-a-half-year-old boy living in Punjab. And there is nine-year-old Suzanne in Imphal. When Tejbir’s mother was 21 weeks pregnant, an ultrasound changed the course of his life. The scan revealed a serious heart abnormality, giving the medical team and the family a critical help in treating CHD: the time to prepare and plan. A stent put in his heart at seven days of age, followed by open-heart surgery after nine months, helped turn a potentially life-threatening diagnosis into a manageable one. Nine-year-old Suzanne was brought to hospital with fever, severe hypertension, and abnormal heartbeats. Tests showed she had an enlarged heart. Since Imphal had no paediatric cardiologist, her family had taken her to Apollo Hospital in Delhi.
She was diagnosed with Takayasu’s arteritis, a rare autoimmune disease that causes blood vessels to narrow. Her blood pressure was dangerously high. “The heart failure was not an isolated heart problem; it was the consequence of different conditions in the body that had driven the child’s blood pressure to dangerous levels,” says Dr Vikas Kohli, Senior Pediatric Cardiologist at Apollo. Suzanne underwent stenting and ballooning procedures in vessels supplying blood to the heart and kidneys, followed by months of hospital care. “Her heart function has improved, her blood pressure medicines have been reduced, and she is taking small but significant steps towards normal life,” says her father, Churchill. He hopes she will soon return to school.
The Geography of Cure
Specialised centres remain concentrated in major cities, families often have to travel hundreds of kilometres, and the cost of treatment, lack of awareness and delayed referrals can turn a treatable condition into a crisis. The challenge, therefore, is no longer simply whether India can treat congenital heart disease. In many cases, it can. The bigger question is whether children can reach the right care early enough. The problem is also lifelong. As survival improves, more children with CHD reaching adolescence and adulthood need continued specialist follow-up rather than simply a successful childhood operation. For Dr Kohli, who treated both Tejbir and Suzanne, the message is ultimately hopeful: once the appropriate intervention is done, “the patient is as good as normal in most cases, however some do need follow up.”
Tejbir’s story began with a diagnosis before birth. Suzanne’s began with a crisis hundreds of kilometres from specialist care. Both eventually reached the treatment they needed. The next frontier for India is to ensure that geography, awareness, specialist availability and affordability do not determine which children get that chance. This is not simply a medical failure; it is a geographical one. The states where the shortage is most acute read like a casualty list: Bihar, Uttar Pradesh, Punjab, Jammu and Kashmir, Himachal Pradesh. In some of these states, just one or two paediatric cardiologists serve populations the size of small countries.
The Blue Baby You Can’t See
For decades, the image of a sick child’s heart in India was a cinematic one: the blue-lipped infant, the murmur a doctor catches almost by accident, the operating table, the recovery, the redemption arc. But paediatric cardiologists indicate a parallel journey which doesn’t involve a defect at all but a perfectly normal-looking teenager. “Early-onset hypertension, early-onset diabetes, early-onset obesity will cause early-onset heart disease,” says Dr Kohli. The data back him up, data that are startling.
A review of 64 Indian studies found roughly 7 per cent of children and adolescents already have hypertension. The World Obesity Atlas estimates 41 million Indian children are overweight or obese in a country simultaneously fighting undernutrition in different corners of the population: malnourished toddlers in one district, and metabolic syndrome brewing in a classroom 200 kilometers away. This is not simply about children being “too fat”. It is about what that weight may mean for their health trajectory. Childhood obesity increases the likelihood of metabolic abnormalities, including high blood pressure and dyslipidemia—a condition causing unhealthy levels of blood fats such as cholesterol and triglycerides—while also increasing the chances of obesity persisting into adulthood.
Southern states including Kerala, Tamil Nadu, and Andhra Pradesh, along with Union Territories such as Puducherry and Chandigarh, report particularly high concentrations of overweight and obese individuals. Together, these numbers raise a crucial question: are we waiting until adulthood to detect a problem that may already be taking shape during childhood and adolescence? Dr Nishith Chandra, at Fortis Escorts Hospital, remembers his youngest heart-failure patient: 19, maybe 20 years old. “For a patient to have had a heart attack at this age,” he says, “the disease must have started very early in his life. Maybe adolescence or even earlier.” Thirteen-year-old Ridhi (name changed) from Delhi started getting headaches. Her energy was low: her parents, both physicians, spent days chasing down the symptoms. The eventual diagnosis was high blood pressure. Her hypertension was not chronic, but it was an alarm that cardiovascular risks can accumulate much earlier than usually imagined. The warning signs, therefore, may be visible well before adulthood. “A child may not be born with a defective heart. The cardiovascular risk may instead accumulate during childhood,” Dr Chandra says. Cardiovascular disease may announce itself in adulthood, but its foundations can be laid much earlier through diet, sleep, physical activity, weight, blood pressure, and the metabolic changes that accompany them.
A Country That Can Fix Hearts, If You Can Find One
Here is the strange paradox of Indian medicine in 2026: the expertise exists. Survival rates for complex congenital heart surgery at India’s top centers now rival those in London or Boston: above 80 to 85 per cent for serious defects, above 95 per cent for the more common ones. A 2026 meta-analysis of 33 Indian studies puts the incidence of congenital heart disease at just over one per cent of live births, which sounds almost reasonable until you do the arithmetic: 2,00,000 to 2,40,000 babies a year, in a country where the specialists who can treat them are clustered in a handful of cities.
In Kashmir, a 10-year-old boy spent years essentially under house arrest by his own heart. His grandmother was afraid he wouldn’t survive the surgery he needed, so instead he didn’t have it. He watched other children play from a window. That was his childhood: restrictions, distances, a door he wasn’t allowed through. “Seven out of ten children with congenital heart disease die in Kashmir,” says Dr Altaf Bhukari, a physician from Kashmir based in Saudi Arabia, who, in 2021, founded a small NGO called the Health and Hope Foundation after realising there was no organised system to get sick children out of the Valley, and into surgery. “A few children would get help. But most of the kids wouldn’t.” He estimates 2,000 children are born with heart defects in Kashmir every year. Some 1,500 of them need real intervention. Roughly 80 per cent, he believes, don’t get it in time.
A relevant case is Usman’s, eight months old when diagnosed with Tetralogy of Fallot, a complex congenital heart defect that limits the amount of oxygen reaching the body. Even after he was referred to a hospital outside the state, surgery was ruled out due to his low WBC counts. Even an attempt to place a stent failed. “When it became a matter of life and death, the doctors at Amrita Hospital, on the family’s insistence, took a leap of faith and performed a very difficult operation on him. The recovery was slow, but he is well now,” says Dr Bhukari. Usman is six years old today. Dr Ashish Katewa, Professor and Head of Pediatric Surgery, Amrita Institute of Medical Sciences, Faridabad, NCR, who operated on Usman, says many such surgeries are performed under the Ayushman Bharat scheme, as the children come from low-income families. But even when the cost of surgery is covered, reaching the hospital, arranging accommodation and managing the logistics of prolonged treatment can remain overwhelming for families.
Prevention Beats Cure
Survival for many conditions at specialist centres is now above 80-85 per cent, and for some common defects, above 95 per cent. Knowing before delivery that a baby has a critical heart defect allows doctors to plan the birth at a specialist centre, prepare neonatal care and intervene before the child becomes critically ill. Doctors caution against drawing a simple line between the apparent rise in congenital heart disease and environmental factors because more diagnoses do not necessarily mean the disease itself is becoming more common. “We don’t have hard data to say that congenital heart disease is increasing. But why we see more of them is because now there is awareness and there is access to diagnostic modalities,” says Dr Katewa. “Maybe 50 years back, or even 30 years back, they were not being diagnosed and were dying without us even knowing what killed a child.”
It’s all in the Genes
Asked whether environmental pollution or the food we eat can cause congenital heart disease, the doctors stop short of making a direct correlation in the absence of supporting epidemiological evidence. The relationship between genes and environment, they say, is complex. “The cause of any genetic defect is a complex interaction of genes and the environment in which we live. These toxins affect genes and can cause gene mutations. Genes code everything,” explains Dr Katewa. “When the heart is being formed, if there are certain chemicals or toxins in the bloodstream, then gene mutations can result in heart defects.” Some defects, he adds, may be so severe that they do not result in a live birth. “Many of these heart defects would be so severe that the foetus will be aborted and will not even be born,” he says. The question India needs to ask is not simply how many children are born with heart disease, but how many are growing up with cardiovascular risk factors that could damage their hearts later in life. The challenge, in other words, is not only to treat congenital heart disease early, but to prevent the conditions that could shape cardiovascular health for decades to come. And whether those risks can be detected and reversed before adulthood. For generations, a child with a heart problem in India was imagined as a child born with one: a baby struggling to breathe, a newborn unable to feed properly, a schoolchild who tired unusually quickly, or a murmur detected by a doctor that led to an echocardiogram and, eventually, a diagnosis of congenital heart disease. That remains a major part of India’s paediatric cardiology burden.
Children Under Pressure
But it is no longer the whole story. Today, paediatric cardiologists are increasingly encountering a different kind of patient: the apparently healthy schoolchild whose blood pressure is too high; the teenager carrying excess weight and showing abnormal cholesterol; the child spending much of the day sitting in classrooms, tuition centres or in front of screens; the adolescent whose metabolic risk is quietly accumulating. Could some of the cardiovascular disease India sees in adults be beginning in childhood? The evidence does not suggest that children are suddenly developing the same heart disease as 60-year-olds. It does, however, show that cardiovascular risk factors can emerge surprisingly early.
For years, high blood pressure has been viewed largely as an adult disease. But Indian research suggests the problem can begin much earlier. A systematic review of 64 studies found hypertension in about 7 per cent of Indian children and adolescents, while another meta-analysis estimated hypertension in 7.6 per cent of Indian adolescents aged 10-19 published in the Indian Journal of Pediatrics. Among children aged 10-12, 35.1 per cent had blood pressure readings in the stage 1 or stage 2 hypertension range; the corresponding figure among those aged 13-19 was 25.1 per cent. But a blood-pressure reading in the hypertension range is not, by itself, a diagnosis of chronic hypertension in a child. Proper diagnosis requires repeated measurements and interpretation based on age, sex and height. The story of childhood heart health, therefore, is becoming broader. It is no longer only about finding the child whose heart was formed differently before birth. It is also about identifying the apparently healthy child whose cardiovascular future may already be taking shape and intervening before risk becomes disease.
Evidence is not Thin
The single idea that reframes everything else in this story belongs to Dr K Srinath Reddy, one of India’s most eminent cardiologists and the founding chairman of the Public Health Foundation of India. He calls it “mismatch programming”, and it goes like this: a baby starved of nutrients in the womb doesn’t just come out small. It comes out adapted, its metabolism quietly rewired to hoard every calorie it can, because scarcity is what it was told to expect. Fast food, sugary drinks, elevators instead of stairs and phone screens instead of books. “We can have a thin-fat baby,” Dr Reddy says, “thin-looking, but carrying dangerous fat around the abdomen, this person can become a thin-fat adult as well.” At least a third of Indian adults with diabetes, he notes, are not overweight at all. They just look fine which is the trap. “India’s younger age of diabetes and heart disease isn’t simply about today’s junk food or sedentary lifestyles,” he says. “Risk may begin much earlier, even before birth.”
It’s a genuinely unsettling idea that a cardiovascular crisis unfolding in Indian adults in their thirties and forties might have its first chapter written in a womb decades earlier, and its second chapter written not by a single bad decision but by an entire modern environment full of pollution, stress, bad sleep, cheap calories , and landing on a body that was never built for abundance.
Setting up Early
The implications extend beyond individual behaviour to the way health systems are designed. Dr Vivek Virendra Singh, health specialist and lead for the Non-Communicable Diseases (NCD) programme at UNICEF India, says health systems must prepare for chronic disease much earlier in life. This is why, he says, UNICEF has included children and NCDs in its programme portfolio. “We need health systems to be geared towards chronic care and not just traditional maternal and child health and acute care. Children with chronic conditions need prevention, promotion and continuous management,” he says. UNICEF India, he adds, is working across two broad areas: health promotion and prevention, addressing risk factors from childhood; and conditions that begin in childhood and become chronic.
An Invisible Enemy
Then there is rheumatic heart disease. “Unlike congenital heart disease, children are not born with rheumatic heart disease. It can follow rheumatic fever, which itself can occur after infection with group A streptococcus. The disease is closely tied to living conditions, overcrowding, access to healthcare, and timely treatment of infections,” says Dr Katewa. It’s a disease of sanitation and access more than of surgical skill, which means, unusually for cardiology, the fix isn’t always in the operating room. Sometimes it’s antibiotics, delivered on time, to a kid with a sore throat in a crowded house. The dangerous part is it can remain silent for long. Indian researchers screened 16,294 schoolchildren aged five to 15 across four sites using echocardiography and World Heart Federation criteria; the study detected rheumatic heart disease in 125 children—7.7 cases per 1,000. “The good news is that this form of heart disease is actually showing downward trends,” says Dr Katewa.
Rheumatic heart disease also underscores a larger truth about paediatric cardiology: not every childhood heart problem can be solved inside a cardiac operating theatre. The cardiovascular story, in other words, does not begin when a child enters a cardiology clinic. It can begin much earlier in the womb, in the home, at school, and in the conditions in which a child grows.
The Catcher in the Right
Congenital heart defects can often be detected and treated. Rheumatic heart disease can, to a large extent, be prevented. High blood pressure can be identified before it becomes entrenched. Obesity and metabolic risk can be addressed early, while physical activity and healthier dietary environments can still become part of a child’s routine rather than a corrective measure imposed later in life. The larger question for India is whether its health system can move from a treatment-led model to a life-course approach to cardiovascular health. The country is already confronting the dual burden of undernutrition and overnutrition; the next phase will be about recognising that both can shape long-term cardiovascular risk.
Childhood is where that future can still be altered. The habits established early, the blood pressure readings that are noticed or missed, the congenital defects identified or overlooked and the metabolic risks addressed or ignored can accumulate into very different adult outcomes. The heart may carry the consequences for decades. But the opportunity to change its trajectory begins much earlier. “Congenital heart disease needs earlier detection and stronger referral pathways,” Dr Kohli says. “Blood pressure needs to become a more routine part of paediatric healthcare. And children with obesity or other risk factors need assessment without stigma.”
Tejbir Singh, the boy whose heart problem was caught before he was born, is running around Punjab right now, blissfully unaware of how much had to go right for that to be possible. Somewhere else, a child just like him is not so lucky, not because the surgery for it doesn’t exist, but because the hospital is four hundred kilometres away, or the specialist retired last year, or the blood pressure cuff never made it into the school nurse’s kit. The heart, it turns out, keeps a diary. It starts writing in it long before anyone thinks to check.