Chest pain in children

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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 only 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

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
  • 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.
  • In children and adolescents aged 10-21 years, chest pain has been reported to cause ≥ 650,000 annual pediatric cardiologist visits.

Risk factors

Common risk factors in the development of chest pain in children include:

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.
  • 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 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
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.

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

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.

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.


Primary Prevention

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

Secondary Prevention

References

  1. Yeh TK, Yeh J.Chest Pain in Pediatrics. Pediatr Ann. 2015; 44:274.
  2. Ji Hye Chun, et al.Analysis of clinical characteristics and causes of chest pain in children and adolescents. Korean J Pediatr. 2015; 58: 440.
  3. Friedman KG, Alexander ME. Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. J Pediatr. 2013; 163:896.
  4. Selbst SM. Approach to the child with chest pain. Pediatr Clin North Am. 2010; 57:1221