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
Historical Perspective
Chest pain in children is a common symptom and have a broad etiology. usually history and physical examination can determine the cause and help in differentiation of patients who require further investigations.
Classification
Chest pain in children can be classified to:
- Cardiac
- Non cardiac
Pathophysiology
- The pathogenesis of chest pain differs according to the cause may be:
- Inflammatory process in myocarditis, pericarditis, Kawasaki disease, Asthma, pneumona, esopahgitis and costocondritis.
- Hypertrophy in hypertrophic cardiomyopathy.
Causes
Common causes of Chest pain in childern include:
Non Cardiac Causes:
Idiopathic
Musculoskeletal
- Muscle strain
- Trauma
- Costochondritis
- Precordial catch syndrome
Respiratory
- Asthma
- Pneumonia
- Pneumothorax
- Pulmonary embolism
- Inhaled foreign body.
- Chronic cough
Gastrointestinal
- Gastroesophageal reflux( GERD)
- Esophagitis
- Gastritis
- Foreign body
Miscellaneous
- Psychogenic and Anexity
- Sickle cell disease
- Herpes zoster
Cardiac Causes:
- Anomalous coronary arteries
- Kawasaki disease
- Dysrhythmias
- Pericarditis
- Myocarditis
- Hypertrophic cardiomyopathy
- Mitral valve prolapse
- Aortic stenosis
- Aortic aneurym
Epidemiology and Demographics
- Patients with chest pain account for 650,000 visits annually in patients age group from10 to 21 years.
- Patients with chest pain account for 5.2% of all cardiology consultations in inpatient and emergency department. and 15% of all outpatient visits.
- Studies estimated only 0% to 5% of patients with chest pain have a cardiac etiology.
Natural History, Complications and Prognosis
- The majority of patients with chest pain have bengin non cardiac causes.
- Prognosis is generally good in non cardiac causes.
Diagnosis
Symptoms
Symptoms of chest pain may include the following:
- Chest wall pain
- Dyspnea
- Cough
- Heart burn
- Pain after taking medications
- Fever
Physical Examination
- Physical examination may be reveals:
- Chest wall tenderness in muscle strain and costochondritis
- Murmur, gallop, pericardial friction rub, distant heart sounds, and abnormal second heart sound (loud S2)
- Irregular rhythm,
- Peripheral edema
- Cyanosis
- Tachypnea
- Skin rash
Laboratory Findings
- Cardiac troponin
- CBC
- CRP
- ESR
Electrocardiogram
An ECG should be obtained if cardiac disease is suspected and when a noncardiac etiology is not clear.
ECG abnormalities can help with diagnosis:
- Dysrrhythmia. However, in intermittent events the initial ECG will be normal.
- Hypertrophic cardiomyopathy: left ventricular hypertrophy or strain.
- Pericarditis: generalized ST segment elevation followed by T wave inversion.
- Myocarditis: ST-T wave abnormalities.
- Anomalous origin of the left coronary artery from the pulmonary artery: anterolateral infarction with deep and wide Q waves and T wave inversions in leads I, aVL, V5, and V6.
- Pulmonary hypertension: signs of right ventricular hypertrophy and right axis deviation.
- Pulmonary embolism: nonspecific ST-T segment changes or sinus tachycardia.
X-ray
An x-ray may be helpful in the diagnosis of the cause of chest pain.
x-ray may showes:
- Cardiac enlargement in myocarditis and pericardial effusion
- Prominent main and central pulmonary arteries. in pulmonary hypertension
- infiltrates in pneumonia
- atelectasis
- Hyperinflation in asthma.
- Pneumothorax, pneumomediastinum, or pleural effusions.
- Radio-opaque esophageal foreign body (eg, button battery, or coin).
Echocardiography or Ultrasound
-Echocardiography may shows many incidental findings but also it can help in the diagnose of serious causes of chest pain, including hypertrophic cardiomyopathy, anomalous coronary artery origin, pericardial effusion, and pulmonary hypertension.
-Echocardiography is indicated in the patients with the following:
- Exertional chest pain or syncope.
- Chest pain associated with fever.
- History of congenital heart disease, Kawasaki syndrome, or diseases that raise cardiac risk (eg, malignancy, hypercoagulable state).
- Family history of cardiomyopathy, sudden death.
- New murmur
- Distant heart sounds
- Pericardial friction rub
- Loud S2
- Peripheral edema
- Abnormal electrocardiogram.
CT scan
CT scan may be helpful in the diagnosis of the cause of chest pain, including pulmonary embolism, aortic aneurysm and disection, and tumors.
MRI
MRI scan may be helpful in the diagnosis of the cause of chest pain, including myocarditis, Arrhythmogenic right ventricular dysplasia (ARVD) and tumors.
Other Diagnostic Studies
Holter monitoring to diagnosis arrhythmia as a cause of intermittent chest pain.
Treatment
Medical Therapy
The managment depend on the clinical status and stability of the patient, patients with sever respiratory distress, hemodynamic instability require rapid care of the (ABC) airway, breathing, and circulation according to the Pediatric Advanced Life Support (PALS).
The medical managment 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, broad spectrum antibiotics, hydration and blood transfusion, or exchange transfusion.
- Pulmonary embolism requires anticoagulant therapy or, thrombolytics in hemodynamic unstable children.
- Ischemia and myocardial infarction should receive anticoagulation, pain management, and catheterization.
- Heart failure should managed with diuretics, ACEIs, and beta blocker if no contrindication.
- Tachyarrhythmias should be managed according to Pediatric Advanced Life Support (PALS).
- Pricarditis with pericardial effusion require pericardiocentesis in patients with tamponade.
- Tumors require further work up and the managment differs according to the type of the tumor.
Surgery
- Aortic root dissection managed with require emergent surgical intervention.
- Tension pneumothorax requires 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 requir urgent removal.