Chest pain in children
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:
Synonyms and keywords: Chest pain in kids
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 in a small subset of patients.
Historical Perspective
Classification
There is no established system for the classification of chest pain in the pediatric population.
Pathophysiology
The pathophysiology of chest pain in children depends on the underlying cause.
Causes
The most common causes of chest pain in children include musculoskeletal, respiratory, and idiopathic. A comprehensive list of causes of chest pain in children is presented in the table below:
| Causes of pediatric chest pain |
| Musculoskeletal |
|
| Respiratory |
|
|
|
| Psychogenic |
| Gastrointestinal |
| Cardiac |
|
| Miscellaneous |
|
| Idiopathic |
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.
- In children and adolescents aged 10-21 years, chest pain has been reported to cause ≥ 650,000 annual pediatric cardiologist visits.
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.
- 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
- A throughout history and physical examination will reveal the etiology of chest pain in the majority of children.
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.
- 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 throughout 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:
Musculoskeletal
- Usually well-localized
- Associated with chest wall tenderness, i.e., reproducible with palpation or gentle pressure
- Worse with movement, coughing, and inspiration
Respiratory
- Chest pain from asthma is often interpreted as ‘tightness’. Associated symptoms include dyspnea (shortness of breath), wheezing, and dry cough. In patients with exertion-induced asthma, symptoms are precipitated with physical activity.
- Pleuritic chest pain is usually sharp and localized, and positional, i.e., aggravated by inspiration and coughing.
Psychogenic
- History of anxiety disorders (e.g. panic disorder) and/or stressful life events.
- Hyperventilation is a common associated symptom.
Gastrointestinal
- Retrosternal or epigastric pain
- Typically burning or sharp in nature.
- Eating may exacerbate or improve the pain
- Associates symptoms may include: heartburn, dysphagia, nausea/vomiting, nocturnal cough
Cardiac
- Usually retrosternal, may radiate to the left arm/jaw region.
- Cardiac chest pain is typically described as heaviness or crushing pain
- Chest pain may be precipitated by exertion.
- Associated symptoms include presyncope, syncope, and palpitations.
Other important clues in making the diagnosis of chest pain in children include:
- History of underlying medical conditions that may be associated with chest pain including:
- Asthma
- Congenital heart disease
- Kawasaki disease
- Sickle cell disease
- History of recent trauma, and new or intense physical activity causing muscle overuse/strain
- History or the possibility of recent substance abuse
- Family history of sudden cardiac death, young-onset ischemic heart disease, and inherited arrhythmias such as long QT syndrome or Brugada
Physical Examination
A thorough physical examination is most often all that is needed to establish a definitive diagnosis in children with chest pain. It should include the following:
- Assessment of vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturations.
- Assessment of general appearance, including color (central or peripheral cyanosis), and evidence of anxiety/distress.
- Evaluation of peripheral pulses.
- Inspection of the chest for signs of recent trauma, bruising, deformities or asymmetry, inntercostal retraction, and localized swelling (in particular at costoconndral junctions)
- 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: reproduces pain in slipping rib syndrome.
- Auscultation of lung fields for breath sounds, wheeze, crackles, and pleural rub. Assessment of tatcile fremitus and transmitted voice sounds (egophony, bronchophony, whispered pectoriloquy) may be done if there is clinical suspicious of pulmonary diseases.
- Auscultation of precordium for heart sounds, murmurs, and pericardial rub.
- Examination of the abdomen for signs of tenderness (particularly epigastric), trauma, and organomegaly.
Laboratory Findings
Electrocardiogram
An electrocardiogram (ECG) should be obtained if there is a clinical suspicion of cardiac disease based upon history or physical examination findings.
X-ray
- A chest X-ray should be obtained in children in whom a cardiac or pulmonary disorder or foreign body ingestion is suspected based on history and physical examination.
- Useful x-ray findings and relevant underlying conditions include:
- Signs of cardiac enlargement: heart failure, myocarditis, pericarditis, or pericardial effusion.
- Enlarged aortic root: aortic dissection
- Prominent main and central pulmonary arteries: pulmonary hypertension
- Consolidation: pneumonia
- areas of atelectasis and air trapping: foreign body aspiration
- Hyperinflation: asthma
- In addition, chest X-ray can detect:
- radio-opaque foreign bodies (eg, button battery, coin, or magnet)
- pneumothorax
- pneumomediastinum
- pleural effusions
Echocardiography or Ultrasound
- In patients with clinical suspicion of cardiac disease, an echocardiogram is indicated. Echocardiography may be helpful in:
- Evaluating cardiac structural abnormalities, and ventricular function
- Evaluating valvular structure and function
- Measurement of pulmonary artery pressure and establishing the diagnosis of pulmonary hypertension
- Assessment of the presence and the size of pericardial effusion and evaluating the signs of tamponade (including variation in Doppler peak velocity across the valves during the cardiac cycle, atrial free wall collapse, or ventricular septal paradoxical motion into the left ventricle during inspiration)
- Diagnosing coronary artery abnormalities, including abnormal origin or course, fistula, aneurysm, and stenosis (caused by Kawasaki disease)
- Diagnosing aortic root dissection
- In clinically unstable patients, ultrasound may help in the diagnosis of pneumothoraces and pericardial effusions and guide intervention (eg, chest tube thoracostomy or pericardiocentesis.
CT scan
- CT scan may be helpful in the diagnosis of cardiac diseases, pulmonary diseases and foreign body ingestion/aspiration.
MRI
Other Diagnostic Studies
Holter monitoring to diagnose arrhythmia as a cause of intermittent chest pain.
Treatment
Medical Therapy
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 medical management of stable patients differs according to the cause:
- Costochondritis and ms strain can be treated with NSAIDs and muscle relaxants.
- Infections like pneumonia can be treated with antibiotics, supplemental oxygen, and mechanical ventilation as needed
- Gastritis and esophagitis can be treated with H2 blockers and PPIs.
- Acute chest syndrome in sickle cell disease managed with pain control, antibiotics, hydration and blood transfusion, or exchange transfusion.
- Pulmonary embolism requires anticoagulant therapy or, thrombolytics in hemodynamically unstable children.
- Ischemia and myocardial infarction should receive anticoagulation, pain management, and catheterization.
- Heart failure should be managed with diuretics, ACEIs, and beta-blocker if no contrindication.
- Tachyarrhythmias should be managed according to Pediatric Advanced Life Support (PALS).
- Pericarditis with pericardial effusion requires pericardiocentesis in patients with tamponade.
- Tumors require further workup and the management differs according to the type of the tumor.
Surgery
- Aortic root dissection managed with requires emergent surgical intervention.
- Tension pneumothorax requires a needle or chest tube thoracostomy.
- Airway foreign body with obstruction requires emergent securing of the airway and bronchoscopy.
- Esophageal foreign body: management depends on the type of body. sharp foreign bodies, impacted batteries, or magnets require urgent removal.
References
- Yeh TK, Yeh J.Chest Pain in Pediatrics. Pediatr Ann. 2015; 44:274.
- Ji Hye Chun, et al.Analysis of clinical characteristics and causes of chest pain in children and adolescents. Korean J Pediatr. 2015; 58: 440.
- Friedman KG, Alexander ME. Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. J Pediatr. 2013; 163:896.
- Selbst SM. Approach to the child with chest pain. Pediatr Clin North Am. 2010; 57:1221