Chest pain can be the presenting complaint for a child feeling chest tightness, burning, pressure, stabbing sensations, palpitations, or heartburn. This can make quickly discerning an etiology difficult, particularly in young children who are not able to verbalize precise symptoms. Chest pain as a symptom affects equal numbers of girls and boys and children under and over 12 years of age. Diagnostically, children younger than 12 years with chest pain are more likely to have cardiorespiratory etiologies for their pain; whereas, adolescents are more likely to have musculoskeletal or psychogenic etiologies.
The general public has been adequately educated on the significant morbidity and mortality that chest pain can imply in adults in the form of cardiac ischemia. Therefore, when children complain of chest pain, it can provide significant anxiety for patients, families, and providers. Due to this anxiety, cardiology consultation is often sought. Unlike adults, underlying cardiac pathology is rare in children with chest pain. Only 4-6% of children without known congenital heart disease are found to have a cardiac etiology. The challenge for the medical care provider is to distinguish chest pain as a commonly benign pediatric complaint from significant cardiac disease, limit unnecessary evaluation, and provide adequate reassurance for an anxious patient and family.
Due to the rarity of cardiac pathology as the cause for chest pain, it is difficult to develop evidence-based guidelines for evaluation, and the implication of a misdiagnosis of a serious disorder is high. Chest pain caused by noncardiac causes may be the combination of multiple diagnoses, leaving medical providers seeking to “rule out” life-threatening cardiac causes of chest pain. The evaluation, if nonconclusive, can leave patients and families without precise answers. Most final diagnoses of noncardiac chest pain represent clinical impressions rather than confirmed diagnoses; between 20 and 45% of pediatric cases of chest pain are labeled idiopathic. The lack of a defined etiology or the presence of multiple causes for a particular patient can heighten worry, anxiety and subsequent morbidity, which is reflected in missed days of school, reduced exercise, and psychologic distress. Furthermore, chest pain can become a chronic condition in the pediatric population; up to 45-69% of patients have been noted to have persistent symptoms with 19% of patients reporting symptoms lasting for more than 3 years.
Overall, if medical providers methodically approach a child or adolescent’s complaint of chest pain, they can provide thoughtful diagnostic evaluations that not only discover serious cardiac pathology if present but also reassure families when a noncardiac etiology is suspected.
Causes of Chest Pain
The most common causes of chest pain in descending frequency include idiopathic, musculoskeletal, pulmonary, psychogenic, gastrointestinal, and cardiac diagnoses ( Table 7.1 ). A differential diagnosis of pediatric chest pain is listed in Table 7.2 . The etiology of chest pain in the absence of cardiac pathology can be multifactorial and includes multiple items on this list.
| Idiopathic | 12-85% |
| Musculoskeletal | 15-31% |
| Pulmonary | 12-21% |
| Psychiatric | 5-17% |
| Gastrointestinal | 5-7% |
| Cardiac | 4-6% |
| Other | 4-21% |
| Musculoskeletal |
|
| Pulmonary |
|
| Psychiatric |
|
| Gastrointestinal |
|
| Cardiac |
|
| Other |
|
Approach to the Patient With Chest Pain
(See Nelson Textbook of Pediatrics, p. 2155.)
A practical approach to chest pain first requires a detailed history and physical examination. An awareness of indicators (red flags) and prioritization that may suggest serious disease and necessitate immediate treatment are essential ( Table 7.3 and Table 7.4 ). In particular, children and adolescents who have chest pain or syncope that is exertional should be taken seriously, particularly if there is a family history of sudden death . Children rarely come in complaining of “shortness of breath on exertion” or “palpitations.” Instead, children should be asked if they keep up with their same-age peers when participating in activities, if they finish last in races, or whether they have to pause in the middle of a flight of stairs. If concerned for palpitations, a provider can ask if a child’s heart ever skips a beat or seems to do flip flops or somersaults in their chest. If red flags are not present but a potentially serious noncardiac etiology of chest pain is suspected, a continued investigation of the pain itself is necessary to make a diagnosis; it can also serve as a therapeutic intervention. A deliberate, orderly, and complete approach to the clinical evaluation often calms an anxious child and family.
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| Category 1: Does the Complaint Indicate Life-Threatening Emergency, Such As… |
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| Indicators: |
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| Category 2: Does the Complaint Indicate a Chronic Condition That Might Result in Serious Complications, Such As… |
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| Category 3: Does the Complaint Indicate Specific Acute Causes, Such As… |
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| Indicators: |
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| Category 4: Does the Complaint Indicate Specific Chronic Causes, Such As… |
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| Indicators: |
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A complete history and physical examination usually with an electrocardiogram (ECG) used to diagnose chest pain allows medical providers to avoid missing life-threatening cardiac pathology. Further testing has been debated when this evaluation indicates a noncardiac diagnosis as the vast majority of patients with a cardiac cause of chest pain have had suggestive symptoms (exertional chest pain, concerning family history findings, abnormal examination findings, and/or abnormal ECG findings), which appropriately lead to further investigation. The considerable anxiety generated among patients, families, and even providers in regard to this symptom can promote evaluations that are extensive, costly, and often low yield.
History
The goal of a thorough history of a patient with chest pain is to determine if the etiology is life threatening, a manifestation of a chronic condition with possible serious complications, a specific acute cause or multiple acute and/or chronic causes. Although chest pain affects children and adolescents of all ages equally, the age of a child can assist in diagnosis. Adolescents are more likely to have musculoskeletal or psychogenic causes of chest pain, while younger children have more respiratory disorders and vague complaints.
One possible approach includes a stepwise, directed history that includes:
- •
Description of pain ( Table 7.5 )
TABLE 7.5
Historical Features of Chest Pain That Are Essential to Its Assessment
Duration of pain (how long present but also duration of each episode)
Acuteness of onset
Severity of pain (use scale of 1-10)
Associated symptoms
Precipitating and ameliorating factors
Quality of pain (pleuritic, sharp, dull)
Location of pain
Limitation of activities by pain
Radiation of pain
Time of day that pain occurs
Recent activity, injury, and stresses
Full psychosocial review, including behaviors
Medical history
Family medical history
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Assessment for red-flag symptoms, including targeted family history
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Medication review
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Review of known illnesses
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Review of systems including psychosocial evaluation
Eliciting the basics of the chest pain’s duration, quality, propensity to radiate, severity, and timing is essential. Details that have been noted to be particularly helpful include duration, aggravating and relieving factors, and associated symptoms. Severe pain that lasts only a few seconds up to 1 or 2 minutes is often from the chest wall, but chest pain that persists longer is more likely to be organic in nature. Aggravating and alleviating factors can include position changes that accompany the pain from pericarditis or onset after eating spicy foods in gastroesophageal reflux. The character and location of the pain in pediatric patients are less helpful in the diagnostic evaluation due to often vague descriptions; nonetheless, medical providers should continue to obtain this information to understand the whole picture. Providers should remember that children often complain of chest pain when the pain is in a different place, such as the epigastrium or flank. Finally, it is important to determine whether or not the chest pain has had an impact on the child’s activity.
Red-flag symptoms (see Table 7.3 ) are high-yield, must-know characteristics of a child or adolescent’s chest pain. Oftentimes, after a patient’s complete description of the pain, a medical provider will already know the answers to multiple red-flag symptoms, such as when the pain occurs, if it wakes the patient from sleep, and if it is associated with syncope. A targeted family history includes asking about inherited conditions such as familial hypercholesterolemia, hypertrophic cardiomyopathy, asthma, and Marfan syndrome. It also can provide information regarding relatives with adult-onset cardiac illnesses associated with chest pain, such as heart failure or ischemia, which may be providing added anxiety for the family.
Medications that the child may already be taking are important to consider. Some medications have specific links to etiologies of chest pain, such as tetracyclines with erosive esophagitis or oral contraceptives with pulmonary embolism. Other illicit medications such as cocaine and other sympathomimetic agents (such as amphetamines, synthetic marijuana) have been associated with chest pain. A child’s known underlying illnesses and surrounding medical complaints discovered in a review of systems can complete the clinical picture for medical providers. The presence of joint pain or rash could suggest collagen vascular disease or the presence of increased drooling could represent an esophageal foreign body.
A full psychosocial review should be performed on each patient to ensure that details of personal stressors and behaviors emerge. It is useful to learn about these aspects of the child’s chest pain from the child and the parent/family separately. Make sure to interview the patient alone if the child is older or an adolescent. It is difficult for children to discuss areas of difficulty, such as family relationships, school difficulties or concerns about physical development, with family present. It is useful to ask “What are you concerned that this pain is caused by?” of both the patient and the family. This question frequently gives information about overriding fears and concerns that can help medical providers know how to appropriately reassure the family in the likely event that the chest pain has a benign, noncardiac etiology.
Musculoskeletal
Musculoskeletal chest wall pain is perhaps the most identifiable cause of chest pain due to its association with localized tenderness elicited by specific manipulation of the thorax ( Fig. 7.1 ). Pain can involve the ribs, costochondral junctions, costal cartilages, intercostal muscles, sternum, clavicle, or spine. The pain is often worse with movement, coughing, and inspiration. In considering musculoskeletal etiologies, thoroughly consider any trauma to the chest wall. Both contusion and rib fracture can be particularly painful with exquisite tenderness on palpation and pain on inspiration. Table 7.6 highlights common causes of musculoskeletal chest pain.
| Signs and Symptoms | Diagnosis |
|---|---|
| Aching pain after new or intense exercise or repetitive coughing Can appear up to 2 days later Pain reproduced by range of motion testing or palpation | Muscular strain |
| Sharp, anterior pain over costochondral junctions Exacerbated by deep breathing 1st through 5th ribs are most common | Costochondritis |
| Sharp, localized pain at one costochondral junction Area is swollen, ± warm, erythematous bulbous or fusiform 1-4 cm mass 2nd or 3rd costochondral junction is most common Age predominance in adolescents and early twenties | Tietze syndrome |
| Pain and increased mobility of 8th, 9th, or 10th ribs (which are not attached to the sternum), resulting in impingement of superior intercostal nerve Intermittent sharp pain in chest or upper abdomen Brought on by exertion, especially sudden upward and anterior movement (“hooking maneuver”; see Fig. 7.2 ) Can have popping sensation at onset of pain Caused by trauma or dislocation of these ribs | Slipping rib syndrome (lower rib pain syndrome) |
| Brief (30 sec–3 min), nonradiating, sharp pain in the left parasternal area or cardiac apex (“Texidor twinge”) Occurs at rest or with mild activity Exacerbated with inspiration and alleviated by shallow breathing or straightened position Related to poor posture | Precordial catch syndrome |
| Pain over both anterior chest and back Spasm in muscles innervated by nerve root causes pain No midline spine bony tenderness History of vertigo, headache, pain after prolonged recumbence or straining | Spinal cord or nerve root compression, typically lower cervical or upper thoracic spine |
| Chronic aching and stiffness Multiple points of tenderness on palpation of muscle with minimal pressure Associated with fatigue and sleep disturbance | Fibromyalgia |
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