Chest pain in children: Difference between revisions

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==Overview==
==Overview==


Chest pain is a common symptom in children and adolescents. Despite causing considerable concerns and anxiety in patients and their families, most cases have benign and non-cardiac etiologies. A throughout history and physical examination can reveal diagnoses in the majority of patients, necessitating laboratory testing and imaging studies only in a small subset of patients.
Chest pain is a common [[symptom]] in children and adolescents. Despite causing considerable concerns and anxiety in [[patients]] and their families, most cases have [[benign]] and non-[[cardiac]] etiologies. A thorough history and [[physical examination]] can reveal [[diagnoses]] in the majority of [[patients]], necessitating laboratory testing and [[imaging]] studies only in a small subset of [[patients]].


==Historical Perspective==
==Historical Perspective==
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==Diagnosis==
==Diagnosis==
===Diagnostic Study of Choice===
===Diagnostic Study of Choice===
*A thorough[[history]] and [[physical examination]] will reveal the etiology of [[chest pain]] in the majority of children. <ref name="pmid24301714">{{cite journal| author=Collins SA, Griksaitis MJ, Legg JP| title=15-minute consultation: a structured approach to the assessment of chest pain in a child. | journal=Arch Dis Child Educ Pract Ed | year= 2014 | volume= 99 | issue= 4 | pages= 122-6 | pmid=24301714 | doi=10.1136/archdischild-2013-303919 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24301714  }} </ref>
*A thorough [[history]] and [[physical examination]] will reveal the etiology of [[chest pain]] in the majority of children. <ref name="pmid24301714">{{cite journal| author=Collins SA, Griksaitis MJ, Legg JP| title=15-minute consultation: a structured approach to the assessment of chest pain in a child. | journal=Arch Dis Child Educ Pract Ed | year= 2014 | volume= 99 | issue= 4 | pages= 122-6 | pmid=24301714 | doi=10.1136/archdischild-2013-303919 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24301714  }} </ref>


===History and symptoms===
===History and symptoms===
*A detailed [[history]] is of crucial importance when assessing a child with [[chest pain]] as it can help to make a definitive diagnosis in the majority of pediatric patients with [[chest pain]]. <ref name="pmid23769502">{{cite journal |vauthors=Friedman KG, Alexander ME |title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease |journal=J Pediatr |volume=163 |issue=3 |pages=896–901.e1–3 |date=September 2013 |pmid=23769502 |pmc=3982288 |doi=10.1016/j.jpeds.2013.05.001 |url=}}</ref><ref>{{cite journal|doi=10.3345/2Fkjp.2015.58.11.440}}</ref><ref name="IvesDaubeney2010">{{cite journal|last1=Ives|first1=A.|last2=Daubeney|first2=P. E. F.|last3=Balfour-Lynn|first3=I. M.|title=Recurrent chest pain in the well child|journal=Archives of Disease in Childhood|volume=95|issue=8|year=2010|pages=649–654|issn=0003-9888|doi=10.1136/adc.2008.155309}}</ref><ref name="pmid24301714">{{cite journal| author=Collins SA, Griksaitis MJ, Legg JP| title=15-minute consultation: a structured approach to the assessment of chest pain in a child. | journal=Arch Dis Child Educ Pract Ed | year= 2014 | volume= 99 | issue= 4 | pages= 122-6 | pmid=24301714 | doi=10.1136/archdischild-2013-303919 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24301714  }} </ref>
*A detailed [[history]] is of crucial importance when assessing a child with [[chest pain]] as it can help to make a definitive diagnosis in most pediatric patients with [[chest pain]]. <ref name="pmid23769502">{{cite journal |vauthors=Friedman KG, Alexander ME |title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease |journal=J Pediatr |volume=163 |issue=3 |pages=896–901.e1–3 |date=September 2013 |pmid=23769502 |pmc=3982288 |doi=10.1016/j.jpeds.2013.05.001 |url=}}</ref><ref>{{cite journal|doi=10.3345/2Fkjp.2015.58.11.440}}</ref><ref name="IvesDaubeney2010">{{cite journal|last1=Ives|first1=A.|last2=Daubeney|first2=P. E. F.|last3=Balfour-Lynn|first3=I. M.|title=Recurrent chest pain in the well child|journal=Archives of Disease in Childhood|volume=95|issue=8|year=2010|pages=649–654|issn=0003-9888|doi=10.1136/adc.2008.155309}}</ref><ref name="pmid24301714">{{cite journal| author=Collins SA, Griksaitis MJ, Legg JP| title=15-minute consultation: a structured approach to the assessment of chest pain in a child. | journal=Arch Dis Child Educ Pract Ed | year= 2014 | volume= 99 | issue= 4 | pages= 122-6 | pmid=24301714 | doi=10.1136/archdischild-2013-303919 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24301714  }} </ref>
*Particular attention should be paid to the nature of the pain, its characteristics, and associated [[symptom]]s.
*Particular attention should be paid to the nature of the pain, its characteristics, and associated [[symptom]]s.
*Younger children may interpret a wide range of [[symptom]]s and even unpleasant sensations in their chest wall as [[chest pain]]. A thorough [[history]] may help differentiate true chest pain from these unusual sensations.   
*Younger children may interpret a wide range of [[symptom]]s and even unpleasant sensations in their chest wall as [[chest pain]]. A thorough [[history]] may help differentiate true chest pain from these unusual sensations.   
*The important characteristics of [[chest pain]] that can help to differentiate the underlying etiology are as follows:
*The important characteristics of [[chest pain]] that can help to differentiate the underlying etiology are:
===== [[Musculoskeletal]]  =====
===== [[Musculoskeletal]]  =====
*Usually well-localized
*Usually well-localized
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===Physical Examination===
===Physical Examination===
*A thorough [[physical examination]] is most often all that is needed to establish a definitive diagnosis in children with [[chest pain]]. <ref name="pmid24301714">{{cite journal| author=Collins SA, Griksaitis MJ, Legg JP| title=15-minute consultation: a structured approach to the assessment of chest pain in a child. | journal=Arch Dis Child Educ Pract Ed | year= 2014 | volume= 99 | issue= 4 | pages= 122-6 | pmid=24301714 | doi=10.1136/archdischild-2013-303919 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24301714  }} </ref>  
*A thorough [[physical examination]] is most often all that is needed to establish a definitive diagnosis in children with [[chest pain]]. <ref name="pmid24301714">{{cite journal| author=Collins SA, Griksaitis MJ, Legg JP| title=15-minute consultation: a structured approach to the assessment of chest pain in a child. | journal=Arch Dis Child Educ Pract Ed | year= 2014 | volume= 99 | issue= 4 | pages= 122-6 | pmid=24301714 | doi=10.1136/archdischild-2013-303919 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24301714  }} </ref>  
*Initial assessment should focus on identifying signs of [[cardiorespiratory distress]]. Patients with any of the following findings on [[physical examination]] are more likely to have a serious or life-threatening condition that warrants further diagnostic workup and/or therapeutic intervention.
*Initial assessment should focus on identifying signs of [[cardiorespiratory distress]]. Patients with any of the following findings on [[physical examination]] are more likely to have a serious or life-threatening condition that warrants further diagnostic workup and/or therapeutic intervention:
**[[Dyspnea]], [[tachypnea]], increased work of breathing
**[[Dyspnea]], [[tachypnea]], increased work of breathing
**[[Hypoxia]]
**[[Hypoxia]]
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**Altered mental state
**Altered mental state
**Therefore, a complete [[physical examination]] should include the following:
**Therefore, a complete [[physical examination]] should include the following:
**Assessment of [[vital signs]], including [[blood pressure]], [[heart rate]], [[respiratory rate]], and [[oxygen saturations]].
**Assessment of [[vital signs]], including [[blood pressure]], [[heart rate]], [[respiratory rate]], and [[oxygen saturations]]
**Assessment of general appearance, including the [[level of consciousness]], color (central or peripheral cyanosis), and evidence of [[anxiety]]/distress, [[dyspnea]], [[tachypnea]], increased work of breathing
**Assessment of general appearance, including the [[level of consciousness]], color (central or peripheral cyanosis), and evidence of [[anxiety]]/distress, [[dyspnea]], [[tachypnea]], increased work of breathing
**Evaluation of [[peripheral pulses]].
**Evaluation of [[peripheral pulses]]
**Inspection of the chest for signs of recent trauma, [[bruising]], deformities or asymmetry, [[intercostal retraction]], and localized swelling (in particular at [[costochondral junctions]])
**Inspection of the chest for signs of recent trauma, [[bruising]], deformities or asymmetry, [[intercostal retraction]], and localized swelling (in particular at [[costochondral junctions]])
**Palpation of the chest for chest wall tenderness (in particular at the location of pain), [[crepitus]], [[heaves]], or [[thrills]].
**Palpation of the chest for chest wall tenderness (in particular at the location of pain), [[crepitus]], [[heaves]], or [[thrills]]
***[[Hooking maneuver]]: hook fingers under lower [[costal margin]] and pull anteriorly- Thia maneuver will reproduce pain in patients with [[slipping rib syndrome]].
***[[Hooking maneuver]]: hook fingers under lower [[costal margin]] and pull anteriorly- this maneuver will reproduce pain in patients with [[slipping rib syndrome]].
**[[Auscultation]] of lung fields for [[breath sounds]], [[wheeze]], [[crackles]], and [[pleural rub]]. Assessment of [[tactile fremitus]] and transmitted voice sounds ([[egophony]], [[bronchophony]], [[whispered pectoriloquy]]) may be done if there is a clinical suspicion of pulmonary diseases.
**[[Auscultation]] of lung fields for [[breath sounds]], [[wheeze]], [[crackles]], and [[pleural rub]]. Assessment of [[tactile fremitus]] and transmitted voice sounds ([[egophony]], [[bronchophony]], [[whispered pectoriloquy]]) may be done if there is a clinical suspicion of pulmonary diseases
**[[Auscultation]] of [[precordium]] for [[heart sounds]], [[murmurs]], and [[pericardial rub]].
**[[Auscultation]] of [[precordium]] for [[heart sounds]], [[murmurs]], and [[pericardial rub]]
**Examination of the abdomen for signs of [[tenderness]] (in particular at [[epigastric]] region)
**Examination of the abdomen for signs of [[tenderness]] (in particular at [[epigastric]] region)


===Laboratory Findings===
===Laboratory Findings===
*Laboratory testing is rarely needed in pediatric patients presenting with [[chest pain]].  
*Laboratory testing is rarely needed in pediatric patients presenting with [[chest pain]]. <ref name="pmid23769502">{{cite journal| author=Friedman KG, Alexander ME| title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. | journal=J Pediatr | year= 2013 | volume= 163 | issue= 3 | pages= 896-901.e1-3 | pmid=23769502 | doi=10.1016/j.jpeds.2013.05.001 | pmc=3982288 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23769502  }} </ref>
*Cardiac [[troponins]] and [[CK-MB]] may be indicated in patients suspected of having cardiac diseases such as [[myocardial infarction]] and [[myocarditis]].
*Cardiac [[troponins]] and [[CK-MB]] may be indicated in patients suspected of having cardiac diseases such as [[myocardial infarction]] and [[myocarditis]].
*Additional laboratory tests include [[serum electrolytes]], a [[complete blood count]], [[renal function tests]], and [[liver function tests]].
*Additional laboratory tests include [[serum electrolytes]], a [[complete blood count]], [[renal function tests]], and [[liver function tests]].
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*A [[chest X-ray]] should be obtained in children in whom a cardiac or pulmonary disorder or foreign body ingestion/or aspiration is suspected based on history and physical examination. <ref name="pmid23769502">{{cite journal| author=Friedman KG, Alexander ME| title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. | journal=J Pediatr | year= 2013 | volume= 163 | issue= 3 | pages= 896-901.e1-3 | pmid=23769502 | doi=10.1016/j.jpeds.2013.05.001 | pmc=3982288 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23769502  }} </ref>
*A [[chest X-ray]] should be obtained in children in whom a cardiac or pulmonary disorder or foreign body ingestion/or aspiration is suspected based on history and physical examination. <ref name="pmid23769502">{{cite journal| author=Friedman KG, Alexander ME| title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. | journal=J Pediatr | year= 2013 | volume= 163 | issue= 3 | pages= 896-901.e1-3 | pmid=23769502 | doi=10.1016/j.jpeds.2013.05.001 | pmc=3982288 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23769502  }} </ref>
*Useful [[x-ray]] findings and relevant underlying conditions include:
*Useful [[x-ray]] findings and relevant underlying conditions include:
*Signs of [[cardiac enlargement]]: [[heart failure]], [[myocarditis]], [[pericarditis]], or [[pericardial effusion]].
*Signs of [[cardiac enlargement]]: [[heart failure]], [[myocarditis]], [[pericarditis]], or [[pericardial effusion]]
*Enlarged [[aortic root]]: [[aortic dissection]]
*Enlarged [[aortic root]]: [[aortic dissection]]
*Prominent main [[pulmonary arteries]]: [[pulmonary hypertension]]
*Prominent main [[pulmonary arteries]]: [[pulmonary hypertension]]
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**Diagnosing coronary artery abnormalities, including abnormal origin or course, fistula, aneurysm, and stenosis (caused by [[Kawasaki disease]])
**Diagnosing coronary artery abnormalities, including abnormal origin or course, fistula, aneurysm, and stenosis (caused by [[Kawasaki disease]])
**Diagnosing [[aortic root dissection]]
**Diagnosing [[aortic root dissection]]
*In clinically unstable patients, ultrasound may help in the diagnosis of [[pneumothorax]] and [[pericardial effusion]]s and guide interventions (eg, [[chest tube thoracostomy]] or [[pericardiocentesis]].
*In clinically unstable patients, ultrasound may help in the diagnosis of [[pneumothorax]] and [[pericardial effusion]]s and guide interventions (eg, [[chest tube thoracostomy]] or [[pericardiocentesis]]


===CT scan===
===CT scan===
*CT scan may be helpful in the diagnosis of several [[cardiac diseases]], [[pulmonary diseases]], and foreign body ingestion/aspiration.
*A CT scan may be helpful in the diagnosis of several [[cardiac diseases]], [[pulmonary diseases]], and foreign body ingestion/aspiration.


===MRI===
===MRI===
*MRI may be helpful in the diagnosis of acute [[aortic dissection]].
*A MRI may be helpful in the diagnosis of acute [[aortic dissection]].


===Other Diagnostic Studies===
===Other Diagnostic Studies===
*A [[24-hour ECG Holter monitoring]] may be used to diagnose [[arrhythmia]].
*A [[24-hour ECG Holter monitoring]] may be used to diagnose [[arrhythmia]]. <ref name="pmid23769502">{{cite journal| author=Friedman KG, Alexander ME| title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. | journal=J Pediatr | year= 2013 | volume= 163 | issue= 3 | pages= 896-901.e1-3 | pmid=23769502 | doi=10.1016/j.jpeds.2013.05.001 | pmc=3982288 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23769502  }} </ref>
*Other imaging studies that may be used in the evaluation of [[chest pain]] include [[V/Q scintigraphy]], [[CT angiography]], and [[upper GI endoscopy]].
*Other imaging studies that may be used in the evaluation of [[chest pain]] include [[V/Q scintigraphy]], [[CT angiography]], and [[upper GI endoscopy]].


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*The management depends on the clinical status and stability of the patient, patients with severe [[respiratory distress]], hemodynamic instability require rapid care of the (ABC) airway, breathing, and circulation according to the [[Pediatric Advanced Life Support]] ([[PALS]]).
*The management depends on the clinical status and stability of the patient, patients with severe [[respiratory distress]], hemodynamic instability require rapid care of the (ABC) airway, breathing, and circulation according to the [[Pediatric Advanced Life Support]] ([[PALS]]).
*Medical management of stable patients depends on the underlying etiology of [[chest pain]]: <ref>{{cite journal|doi=10.1136/2Fadc.63.12.1457}}</ref>
*Medical management of stable patients depends on the underlying etiology of [[chest pain]]: <ref>{{cite journal|doi=10.1136/2Fadc.63.12.1457}}</ref>
*[[Costochondritis]] and muscle strain can be treated with [[rest]], [[warm compression]], [[analgesic]], anti-inflammatory agents ([[NSAID]]s).
*[[Costochondritis]] and muscle strain can be treated with [[rest]], [[warm compression]], [[analgesic]], anti-inflammatory agents ([[NSAID]]s)
*[[Pneumonia]] can be treated with [[antibiotics]], [[supplemental oxygen]], and [[mechanical ventilation]] as needed.
*[[Pneumonia]] can be treated with [[antibiotics]], [[supplemental oxygen]], and [[mechanical ventilation]] as needed
*[[Gastroesophageal reflux disease]] can be treated with [[H2-blockers]] and [[proton pump inhibitors]] ([[PPIs]].
*[[Gastroesophageal reflux disease]] can be treated with [[H2-blockers]] and [[proton pump inhibitors]] ([[PPIs]]
**For a complete guide on the treatments of [[GERD]], [[Gastroesophageal reflux disease medical therapy|click here]].<br />
**For a complete guide on the treatments of [[GERD]], [[Gastroesophageal reflux disease medical therapy|click here]]<br />
*[[Acute chest syndrome]] in patients with [[sickle cell disease]] may be managed with pain control, [[antibiotics]], [[hydration]], [[blood transfusion]], or [[exchange transfusion]].
*[[Acute chest syndrome]] in patients with [[sickle cell disease]] may be managed with pain control, [[antibiotics]], [[hydration]], [[blood transfusion]], or [[exchange transfusion]]
**For a complete guide on the treatments of [[acute chest syndrome]], [[Acute chest syndrome medical therapy|click here]].<br />
**For a complete guide on the treatments of [[acute chest syndrome]], [[Acute chest syndrome medical therapy|click here]]<br />
*[[Pulmonary embolism]] requires [[anticoagulant therapy]] or [[thrombolytic]] in hemodynamically unstable children.
*[[Pulmonary embolism]] requires [[anticoagulant therapy]] or [[thrombolytic]] in hemodynamically unstable children
**For a complete guide on the treatments of [[pulmonary embolism]], [[Pulmonary embolism treatment approach|click here]].<br />
**For a complete guide on the treatments of [[pulmonary embolism]], [[Pulmonary embolism treatment approach|click here]]<br />
*[[Myocardial ischemia]] and [[myocardial infarction]] should receive anticoagulation, pain management, and catheterization.
*[[Myocardial ischemia]] and [[myocardial infarction]] should receive anticoagulation, pain management, and catheterization
*[[Heart failure]] should be managed with [[diuretics]], [[ACEIs]], and [[beta-blockers]] if no contraindications.
*[[Heart failure]] should be managed with [[diuretics]], [[ACEIs]], and [[beta-blockers]] if no contraindications
*[[Tachyarrhythmias]] should be managed according to [[Pediatric Advanced Life Support]] ([[PALS]]).
*[[Tachyarrhythmias]] should be managed according to [[Pediatric Advanced Life Support]] ([[PALS]])
*[[Pericarditis]] with [[pericardial effusio]]n requires [[pericardiocentesis]] in patients with [[tamponade]].
*[[Pericarditis]] with [[pericardial effusio]]n requires [[pericardiocentesis]] in patients with [[tamponade]]
**For a complete guide on the treatments of [[pericarditis]], [[Pericarditis treatment|click here]].<br />
**For a complete guide on the treatments of [[pericarditis]], [[Pericarditis treatment|click here]]<br />


===Surgery===
===Surgery===
Surgical intervention may be indicated in patients with:  
Surgical intervention may be indicated in patients with: <ref name="pmid29963100">{{cite journal| author=Govindarajan KK| title=Esophageal perforation in children: etiology and management, with special reference to endoscopic esophageal perforation. | journal=Korean J Pediatr | year= 2018 | volume= 61 | issue= 6 | pages= 175-179 | pmid=29963100 | doi=10.3345/kjp.2018.61.6.175 | pmc=6021361 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29963100  }} </ref> <ref name="pmid17007168">{{cite journal| author=Fikar CR| title=Acute aortic dissection in children and adolescents: diagnostic and after-event follow-up obligation to the patient and family. | journal=Clin Cardiol | year= 2006 | volume= 29 | issue= 9 | pages= 383-6 | pmid=17007168 | doi=10.1002/clc.4960290903 | pmc=6654457 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17007168  }} </ref> <ref name="pmid30592692">{{cite journal| author=Williams K, Baumann L, Grabowski J, Lautz TB| title=Current Practice in the Management of Spontaneous Pneumothorax in Children. | journal=J Laparoendosc Adv Surg Tech A | year= 2019 | volume= 29 | issue= 4 | pages= 551-556 | pmid=30592692 | doi=10.1089/lap.2018.0629 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30592692  }} </ref> <ref name="pmid32167851">{{cite journal| author=Pogorelić Z, Gudelj R, Bjelanović D, Jukić M, Elezović Baloević S, Glumac S | display-authors=etal| title=Management of the Pediatric Spontaneous Pneumothorax: The Role of Video-Assisted Thoracoscopic Surgery. | journal=J Laparoendosc Adv Surg Tech A | year= 2020 | volume= 30 | issue= 5 | pages= 569-575 | pmid=32167851 | doi=10.1089/lap.2019.0742 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32167851  }} </ref>
*[[Aortic dissection]]  
*[[Aortic dissection]]  
*[[Pneumothorax]]  
*[[Pneumothorax]]  
*[[Pericardial effusion]]
*[[Pericardial effusion]]
*Esophageal/pulmonary foreign body
*Esophageal foreign body
* Pulmonary foreign body


===Primary Prevention===
===Primary Prevention===
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===Secondary Prevention===
===Secondary Prevention===
*High-dose [[aspirin]] (80–100 mg/kg/day) and high-dose [[intravenous immunoglobulin]] ([[IVIG]], 2 g/kg) have been shown to decrease the rate of [[coronary artery aneurysm]]s in children with [[Kawasaki disease]].
*High-dose [[aspirin]] (80–100 mg/kg/day) and high-dose [[intravenous immunoglobulin]] ([[IVIG]], 2 g/kg) have been suggested to decrease the rate of [[coronary artery aneurysm]]s in children with [[Kawasaki disease]]. <ref name="pmid24730626">{{cite journal| author=Research Committee of the Japanese Society of Pediatric Cardiology. Cardiac Surgery Committee for Development of Guidelines for Medical Treatment of Acute Kawasaki Disease| title=Guidelines for medical treatment of acute Kawasaki disease: report of the Research Committee of the Japanese Society of Pediatric Cardiology and Cardiac Surgery (2012 revised version). | journal=Pediatr Int | year= 2014 | volume= 56 | issue= 2 | pages= 135-58 | pmid=24730626 | doi=10.1111/ped.12317 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24730626  }} </ref>
*[[Hydroxyurea]], [[chronic transfusion therapy]], and [[L-glutamine]] may decrease the frequency of acute painful [[vaso-occlusive episodes]], including [[acute chest syndrome]], in patients with [[sickle cell disease]].
*[[Hydroxyurea]], [[chronic transfusion therapy]], and [[L-glutamine]] may decrease the frequency of acute painful [[vaso-occlusive episodes]], including [[acute chest syndrome]], in patients with [[sickle cell disease]]. <ref name="pmid23861242">{{cite journal| author=Alvarez O, Yovetich NA, Scott JP, Owen W, Miller ST, Schultz W | display-authors=etal| title=Pain and other non-neurological adverse events in children with sickle cell anemia and previous stroke who received hydroxyurea and phlebotomy or chronic transfusions and chelation: results from the SWiTCH clinical trial. | journal=Am J Hematol | year= 2013 | volume= 88 | issue= 11 | pages= 932-8 | pmid=23861242 | doi=10.1002/ajh.23547 | pmc=4631259 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23861242  }} </ref> <ref name="pmid30021096">{{cite journal| author=Niihara Y, Miller ST, Kanter J, Lanzkron S, Smith WR, Hsu LL | display-authors=etal| title=A Phase 3 Trial of l-Glutamine in Sickle Cell Disease. | journal=N Engl J Med | year= 2018 | volume= 379 | issue= 3 | pages= 226-235 | pmid=30021096 | doi=10.1056/NEJMoa1715971 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30021096  }} </ref>


==References==
==References==
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[[Category:Primary care]]
[[Category:Primary care]]
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Up-To-Date]]

Latest revision as of 18:08, 16 April 2021
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mitra Chitsazan, M.D.[2]

Synonyms and keywords: Chest pain in kids, pediatric chest pain

Overview

Chest pain is a common symptom in children and adolescents. Despite causing considerable concerns and anxiety in patients and their families, most cases have benign and non-cardiac etiologies. A thorough history and physical examination can reveal diagnoses in the majority of patients, necessitating laboratory testing and imaging studies only in a small subset of patients.

Historical Perspective

There is limited evidence on the historical perspective of chest pain in children.

Classification

There is no established system for the classification of chest pain in the pediatric population.

Pathophysiology

Causes

The most common causes of chest pain in children include musculoskeletal, respiratory, psychogenic, and idiopathic. A comprehensive list of causes of chest pain in children is presented in the table below: [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]

Causes of pediatric chest pain
Musculoskeletal
  • Muscle overuse/strain
Respiratory
  • Severe and/or chronic Cough
  • Foreign body
Psychogenic
Gastrointestinal
Cardiac
Miscellaneous
  • Tumors (chest wall/mediastinal)
Idiopathic

For a complete list of causes of chest pain in children click here.

Differentiating pediatric chest pain from other Diseases

Epidemiology and Demographics

  • Chest pain accounts for 0.3%-0.6% of emergency department visits, 15% of outpatient visits, and 5.2% of cardiology consultations in the pediatric population. [24] [25]
  • In children and adolescents aged 10-21 years, chest pain has been reported to cause ≥ 650,000 annual pediatric cardiologist visits. [24]

Risk factors

Common risk factors in the development of chest pain in children include: [1][2][3][4][5][6][7][8][9][10][11][12][26][27][28][16][29][18]

Screening

There is insufficient evidence to recommend routine screening for chest pain in children.

Natural History, Complications and Prognosis

  • Most cases of chest pain in children are benign, and cardiac causes have been identified in less than 1% of children with chest pain. [24] [30]
  • Despite having benign etiologies, chest pain in children may contribute to school absences, activity restrictions, and significant anxiety in children and their families.
  • The complications of chest pain in children depend on the underlying etiology.

Diagnosis

Diagnostic Study of Choice

History and symptoms

  • A detailed history is of crucial importance when assessing a child with chest pain as it can help to make a definitive diagnosis in most pediatric patients with chest pain. [1][31][32][30]
  • Particular attention should be paid to the nature of the pain, its characteristics, and associated symptoms.
  • Younger children may interpret a wide range of symptoms and even unpleasant sensations in their chest wall as chest pain. A thorough history may help differentiate true chest pain from these unusual sensations.
  • The important characteristics of chest pain that can help to differentiate the underlying etiology are:
Musculoskeletal
  • Usually well-localized
  • Associated with chest wall tenderness, i.e., reproducible with palpation or gentle pressure
  • Worse with movement, coughing, and inspiration
Respiratory
Psychogenic
Gastrointestinal
Cardiac
Other important clues in making the diagnosis of chest pain in children include:

Physical Examination

Laboratory Findings

Electrocardiogram

An electrocardiogram (ECG) should be obtained if there is a clinical suspicion of cardiac disease based upon history orphysical examination findings. [1]

X-ray

Echocardiography or Ultrasound

CT scan

MRI

Other Diagnostic Studies

*For an algorithmic guide on the diagnosis of chest pain in children, click here.

Treatment

Medical Therapy

*For a complete guide on the algorithmic approach to the treatment of chest pain in children, click here.

Surgery

Surgical intervention may be indicated in patients with: [34] [35] [36] [37]

Primary Prevention

There are no established measures for the primary prevention of chest pain in children.

Secondary Prevention

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Friedman KG, Alexander ME (September 2013). "Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease". J Pediatr. 163 (3): 896–901.e1–3. doi:10.1016/j.jpeds.2013.05.001. PMC 3982288. PMID 23769502.
  2. ↑ 2.0 2.1 2.2 Aeschlimann A, Kahn MF (1990). "Tietze's syndrome: a critical review". Clin Exp Rheumatol. 8 (4): 407–12. PMID 1697801.
  3. ↑ 3.0 3.1 3.2 Heinz, George J. (1977). "Slipping Rib Syndrome". JAMA. 237 (8): 794. doi:10.1001/jama.1977.03270350054023. ISSN 0098-7484.
  4. ↑ 4.0 4.1 4.2 Selbst SM (June 1985). "Chest pain in children". Pediatrics. 75 (6): 1068–70. PMID 4000782.
  5. ↑ 5.0 5.1 5.2 Howell, John M. (1992). "Xiphodynia: A report of three cases". The Journal of Emergency Medicine. 10 (4): 435–438. doi:10.1016/0736-4679(92)90272-U. ISSN 0736-4679.
  6. ↑ 6.0 6.1 6.2 Pickering, D (1981). "Precordial catch syndrome". Archives of Disease in Childhood. 56 (5): 401–403. doi:10.1136/adc.56.5.401. ISSN 0003-9888.
  7. ↑ 7.0 7.1 7.2 Wiens L, Sabath R, Ewing L, Gowdamarajan R, Portnoy J, Scagliotti D (September 1992). "Chest pain in otherwise healthy children and adolescents is frequently caused by exercise-induced asthma". Pediatrics. 90 (3): 350–3. PMID 1518687.
  8. ↑ 8.0 8.1 8.2 Evangelista, Juli-anne K.; Parsons, Marytheresa; Renneburg, Anne K. (2000). "Chest pain in children: diagnosis through history and physical examination". Journal of Pediatric Health Care. 14 (1): 3–8. doi:10.1016/S0891-5245(00)70037-X. ISSN 0891-5245.
  9. ↑ 9.0 9.1 9.2 Barth, Charles W.; Roberts, William C. (1986). "Left main coronary artery originating from the right sinus of valsalva and coursing between the aorta and pulmonary trunk". Journal of the American College of Cardiology. 7 (2): 366–373. doi:10.1016/S0735-1097(86)80507-1. ISSN 0735-1097.
  10. ↑ 10.0 10.1 10.2 Lipsitz, Joshua D.; Masia, Carrie; Apfel, Howard; Marans, Zvi; Gur, Merav; Dent, Heather; Fyer, Abby J. (2005). "Noncardiac chest pain and psychopathology in children and adolescents". Journal of Psychosomatic Research. 59 (3): 185–188. doi:10.1016/j.jpsychores.2005.05.004. ISSN 0022-3999.
  11. ↑ 11.0 11.1 11.2 Lee, Jennifer L.; Gilleland, Jordan; Campbell, Robert M.; Simpson, Patricia; Johnson, Gregory L.; Dooley, Kenneth J.; Blount, Ronald L. (2013). "Health care utilization and psychosocial factors in pediatric noncardiac chest pain". Health Psychology. 32 (3): 320–327. doi:10.1037/a0027806. ISSN 1930-7810.
  12. ↑ 12.0 12.1 12.2 Selbst SM (January 1990). "Chest pain in children". Am Fam Physician. 41 (1): 179–86. PMID 2403723.
  13. ↑ . doi:10.7759/2Fcureus.3690. Missing or empty |title= (help)
  14. ↑ . doi:10.2147/2FOAEM.S29942. Missing or empty |title= (help)
  15. ↑ . doi:10.1007/2Fs00383-011-2874-8. Missing or empty |title= (help)
  16. ↑ 16.0 16.1 16.2 Chun JH, Kim TH, Han MY, Kim NY, Yoon KL (November 2015). "Analysis of clinical characteristics and causes of chest pain in children and adolescents". Korean J Pediatr. 58 (11): 440–5. doi:10.3345/kjp.2015.58.11.440. PMC 4675925. PMID 26692880.
  17. ↑ . doi:10.1161/2FCIRCULATIONAHA.113.006702. Missing or empty |title= (help)
  18. ↑ 18.0 18.1 18.2 Swap, Clifford J. (2005). "Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes". JAMA. 294 (20): 2623. doi:10.1001/jama.294.20.2623. ISSN 0098-7484.
  19. ↑ Kane DA, Fulton DR, Saleeb S, Zhou J, Lock JE, Geggel RL (2010). "Needles in hay: chest pain as the presenting symptom in children with serious underlying cardiac pathology". Congenit Heart Dis. 5 (4): 366–73. doi:10.1111/j.1747-0803.2010.00436.x. PMID 20653703.
  20. ↑ . doi:10.7759/2Fcureus.3690. Missing or empty |title= (help)
  21. ↑ . doi:10.2147/2FOAEM.S29942. Missing or empty |title= (help)
  22. ↑ . doi:10.1007/2Fs00383-011-2874-8. Missing or empty |title= (help)
  23. ↑ . doi:10.1161/2FCIRCULATIONAHA.113.006702. Missing or empty |title= (help)
  24. ↑ 24.0 24.1 24.2 Yeh TK, Yeh J (2015). "Chest Pain in Pediatrics". Pediatr Ann. 44 (12): e274–8. doi:10.3928/00904481-20151110-01. PMID 26678235.
  25. ↑ Selbst SM (2010). "Approach to the child with chest pain". Pediatr Clin North Am. 57 (6): 1221–34. doi:10.1016/j.pcl.2010.09.003. PMID 21111115.
  26. ↑ . doi:10.7759/2Fcureus.3690. Missing or empty |title= (help)
  27. ↑ . doi:10.2147/2FOAEM.S29942. Missing or empty |title= (help)
  28. ↑ . doi:10.1007/2Fs00383-011-2874-8. Missing or empty |title= (help)
  29. ↑ . doi:10.1161/2FCIRCULATIONAHA.113.006702. Missing or empty |title= (help)
  30. ↑ 30.0 30.1 30.2 30.3 Collins SA, Griksaitis MJ, Legg JP (2014). "15-minute consultation: a structured approach to the assessment of chest pain in a child". Arch Dis Child Educ Pract Ed. 99 (4): 122–6. doi:10.1136/archdischild-2013-303919. PMID 24301714.
  31. ↑ . doi:10.3345/2Fkjp.2015.58.11.440. Missing or empty |title= (help)
  32. ↑ Ives, A.; Daubeney, P. E. F.; Balfour-Lynn, I. M. (2010). "Recurrent chest pain in the well child". Archives of Disease in Childhood. 95 (8): 649–654. doi:10.1136/adc.2008.155309. ISSN 0003-9888.
  33. ↑ . doi:10.1136/2Fadc.63.12.1457. Missing or empty |title= (help)
  34. ↑ Govindarajan KK (2018). "Esophageal perforation in children: etiology and management, with special reference to endoscopic esophageal perforation". Korean J Pediatr. 61 (6): 175–179. doi:10.3345/kjp.2018.61.6.175. PMC 6021361. PMID 29963100.
  35. ↑ Fikar CR (2006). "Acute aortic dissection in children and adolescents: diagnostic and after-event follow-up obligation to the patient and family". Clin Cardiol. 29 (9): 383–6. doi:10.1002/clc.4960290903. PMC 6654457 Check |pmc= value (help). PMID 17007168.
  36. ↑ Williams K, Baumann L, Grabowski J, Lautz TB (2019). "Current Practice in the Management of Spontaneous Pneumothorax in Children". J Laparoendosc Adv Surg Tech A. 29 (4): 551–556. doi:10.1089/lap.2018.0629. PMID 30592692.
  37. ↑ Pogorelić Z, Gudelj R, Bjelanović D, Jukić M, Elezović Baloević S, Glumac S; et al. (2020). "Management of the Pediatric Spontaneous Pneumothorax: The Role of Video-Assisted Thoracoscopic Surgery". J Laparoendosc Adv Surg Tech A. 30 (5): 569–575. doi:10.1089/lap.2019.0742. PMID 32167851 Check |pmid= value (help).
  38. ↑ Research Committee of the Japanese Society of Pediatric Cardiology. Cardiac Surgery Committee for Development of Guidelines for Medical Treatment of Acute Kawasaki Disease (2014). "Guidelines for medical treatment of acute Kawasaki disease: report of the Research Committee of the Japanese Society of Pediatric Cardiology and Cardiac Surgery (2012 revised version)". Pediatr Int. 56 (2): 135–58. doi:10.1111/ped.12317. PMID 24730626.
  39. ↑ Alvarez O, Yovetich NA, Scott JP, Owen W, Miller ST, Schultz W; et al. (2013). "Pain and other non-neurological adverse events in children with sickle cell anemia and previous stroke who received hydroxyurea and phlebotomy or chronic transfusions and chelation: results from the SWiTCH clinical trial". Am J Hematol. 88 (11): 932–8. doi:10.1002/ajh.23547. PMC 4631259. PMID 23861242.
  40. ↑ Niihara Y, Miller ST, Kanter J, Lanzkron S, Smith WR, Hsu LL; et al. (2018). "A Phase 3 Trial of l-Glutamine in Sickle Cell Disease". N Engl J Med. 379 (3): 226–235. doi:10.1056/NEJMoa1715971. PMID 30021096.
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