Chest pain in children

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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

• The pathophysiology of chest pain in children depends on the underlying cause.
  • For a complete guide on the pathophysiology of asthma, click here.
    
  • For a complete guide on the pathophysiology of gastroesophageal reflux disease (GERD), click here.
    
  • For a complete guide on the pathophysiology of pneumothorax, click here.
    
  • For a complete guide on the pathophysiology of pulmonary embolism, click here.
    

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:

Causes of pediatric chest pain

Musculoskeletal

Costochondritis

Trauma

Muscle overuse/strain

Tietze's syndrome

Precordial catch syndrome

Respiratory

Severe and/or chronic Cough

Asthma (including exercise-induced asthma)/bronchospasm

Foreign body

Pleuritic: Pneumonia Pneumothorax Pulmonary emboli

Psychogenic

Anxiety

Hyperventilation

Gastrointestinal

Gastroesophageal reflux disease (GERD)

Esophagitis

Peptic ulcer disease

Cardiac

Myocarditis

Pericarditis

Arrhythmia

Myocardial ischemia: Anomalous coronary arteries Aortic stenosis Hypertrophic obstructive cardiomyopathy Coronary artery disease vasculitis: Kawasaki disease

Mitral valve prolapse

Miscellaneous

Herpes Zoster

Sickle cell vaso-occlusive crisis (Acute chest syndrome)

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

• When evaluating pediatric chest pain, serious or life-threatening conditions must be differentiated from benign causes.
• Serious or life-threatening causes of chest pain in children include:
  • Aortic dissection
  • Foreign body aspiration or ingestion
  • Myocardial ischemia
  • Myocarditis
  • Pericarditis
  • Pericardial effusion
  • Pneumothorax/tension pneumothorax
  • Pulmonary embolus
  • Status asthmatics

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:

• Chest trauma
• Muscle overuse/strain
• Prior cardiac disease (including congenital heart disease) or surgery
• Hypercoagulable states
• Sickle cell disease
• Chronic respiratory diseases
• Kawasaki disease
• Familial hyperlipidemia syndromes
• Substance abuse (amphetamine, cocaine, or other stimulants)
• Connective tissue diseases

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

• A thorough 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 most 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 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

• 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. It may be seen in patients with pneumothorax and pulmonary emboli.

Psychogenic

• History of anxiety disorders (e.g. panic disorder) and/or recent 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:
  • 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 syndrome

Physical Examination

• A thorough physical examination is most often all that is needed to establish a definitive diagnosis in children with chest pain.
• 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
  • Hypoxia
  • Abnormal pulse or blood pressure
  • Evidence of poor perfusion/shock
  • Distended neck veins
  • Muffled heart sounds
  • Altered mental state
  • 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 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
  • 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
    • 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 precordium for heart sounds, murmurs, and pericardial rub
  • Examination of the abdomen for signs of tenderness (in particular at epigastric region)

Laboratory Findings

• Laboratory testing is rarely needed in pediatric patients presenting with chest pain.
• 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.

Electrocardiogram

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

X-ray

• 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.
• 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 pulmonary arteries: pulmonary hypertension
• Lobar 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 echocardiographic examination 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 paradoxical motion of ventricular septum 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 pneumothorax and pericardial effusions and guide interventions (eg, chest tube thoracostomy or pericardiocentesis

CT scan

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

MRI

• A MRI may be helpful in the diagnosis of acute aortic dissection.

Other Diagnostic Studies

• A 24-hour ECG Holter monitoring may be used to diagnose arrhythmia.
• Other imaging studies that may be used in the evaluation of chest pain include V/Q scintigraphy, CT angiography, and upper GI endoscopy.

*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.

• 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:
• Costochondritis and muscle strain can be treated with rest, warm compression, analgesic, anti-inflammatory agents (NSAIDs)
• 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
  • For a complete guide on the treatments of GERD, click here
    
• 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, click here
    
• Pulmonary embolism requires anticoagulant therapy or thrombolytic in hemodynamically unstable children
  • For a complete guide on the treatments of pulmonary embolism, click here
    
• 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
• Tachyarrhythmias should be managed according to Pediatric Advanced Life Support (PALS)
• Pericarditis with pericardial effusion requires pericardiocentesis in patients with tamponade
  • For a complete guide on the treatments of pericarditis, click here
    

Surgery

Surgical intervention may be indicated in patients with:

• Aortic dissection
• Pneumothorax
• Pericardial effusion
• Esophageal foreign body
• Pulmonary foreign body

Primary Prevention

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

Secondary Prevention

• 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 aneurysms in children with Kawasaki 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.