The epidemiology and associated risk factors of pediatric chest pain are not well described. Several studies report the prevalence of chest pain types among children and adolescents; however, detailed prospective studies that aim to determine continued morbidity, mortality, health-care seeking behaviors, continued medication use, and quality of life are lacking. A greater understanding of pediatric chest pain epidemiology and risk factors is required.
Chest pain among children and adolescents is common ; however, knowledge of the epidemiology of pediatric chest pain and risk factors associated with it is scant. An understanding of the epidemiology of chest pain among children is important, because it provides information about changes that may occur in behavior, culture, and environment, not to mention risk factors and causes of chest pain. Chest pain is an important alarm symptom. In adults, the presence of chest pain conjures up the possibility of a potentially fatal cardiac event. Fear of a serious life-threatening condition also exists for parents of children with acute chest pain, but the literature suggests that pediatric chest pain is generally a benign condition. However, at present, there are very little mortality data related to chest pain as the primary presenting symptom, and further studies are required to validate these claims. The literature is scattered in prevalence studies and other reports on risk factors; this article aims to consolidate this literature and provide an overview of all studies assessing the epidemiology and risk factors of pediatric chest pain.
Systematic review
The search strategy for this review included the following major electronic databases: MEDLINE, EMBASE, and Current Contents (1950–September 2010). The search strategy used combinations of the keywords (1) chest pain, (2) pediatric, (3) children, (4) adolescents, (5) epidemiology, and (6) risk factors. Additional manual searches were made using the reference lists from all published papers. No language restriction was placed on any of the literature searches. The search revealed 219 potential studies. The abstracts of all potential studies were read to determine if they were epidemiologic in nature or on risk factors. There were 69 epidemiologic studies and 27 on risk factors for pediatric chest pain. In the final review, only 36 epidemiologic studies were used. Full versions of these studies were read and the data used in this systematic review.
Epidemiology
The first published study to determine the epidemiology of chest pain amongst children and adolescents was published more than 30 years ago. It was a prospective study of 43 children with a mean age of 12 years. The major categories of chest pain reported from this study were idiopathic chest pain (45%), costochondritis (22.5%), chest pain secondary to bronchitis (12.5%), miscellaneous (10%), chest pain secondary to muscle pain (5%), and chest pain secondary to trauma (5%). The average duration of chest pain varied considerably: idiopathic, approximately 2 years; miscellaneous, around 8 months; costochondritis, 3 months; trauma, just over a week; bronchitis, just under a week; and muscle strain, 1 day. The conclusions reached from this study were that chest pain in children was not as ominous as in adults and that cardiac disease represented a very small proportion of presentations.
Since then, there have been almost 40 studies on the prevalence of chest pain amongst children and adolescents. The study by Driscoll and colleagues was the only one published in the 1970s; however, in the 1980s, there were 11 additional studies and in the 1990s, slightly fewer, with 8 studies published; in the first decade of the twenty-first century, there have been 16 studies. These studies have included 5222 patients from numerous countries around the world ( Table 1 ).
| Study | Year | N | M/F | Age (Mean) | Cardiac (%) | Gastrointestinal (%) | Psychological (%) | Musculoskeletal (%) | Respiratory (%) | Idiopathic (%) |
|---|---|---|---|---|---|---|---|---|---|---|
| Driscoll et al | 1976 | 40 | 22/18 | 12–19 (12.35) | 22.5 | 12.5 | 45 | |||
| Asnes et al | 1981 | 123 | 41/82 | 4–13 | 29 | |||||
| Kashani et al | 1982 | 100 | 13 | |||||||
| Pantell and Goodman | 1983 | 100 | 45 | |||||||
| Fyfe | 1984 | 67 | 40/27 | 8–19 | 6 | 1 | 1 | 2 | 85 | |
| Selbst | 1985 | 267 | ||||||||
| Rowland and Richards | 1986 | 31 | 23/8 | 8–18 | 26 | |||||
| Nudel et al | 1987 | 180 | 112/68 | 5–22 | 18 | |||||
| Selbst et al | 1988 | 407 | 180/227 | 2–19 | 4 | 4 | 9 | 15 | 21 | 21 |
| Berezin et al | 1988 | 51 | 8–20 | 6 | 41 | 53 | ||||
| Selbst et al | 1990 | 149 | 69/80 | (11.34) | 4 | 3 | 11 | 11 | 20 | 34 |
| Rowe et al | 1990 | 336 | 159/166 | 2–18 | 5 | 28 | 19 | 12 | ||
| Woolf et al | 1991 | 17 | (14.00) | 59 | ||||||
| Zavaras-Angelidou et al | 1992 | 134 | 74/60 | 1.2–19 | 19 | 7 | 16 | 12 | 20 | |
| Glassman et al | 1992 | 83 | 42/39 | 1–20 | 48 | 56.6 | ||||
| Wiens et al | 1992 | 88 | 47/41 | 4–20 | ||||||
| Tunaoglu et al | 1995 | 100 | 46/54 | 2.5–16 | 74 | 92 | ||||
| Gunther et al | 1999 | 456 | 4–17 | |||||||
| Silva et al | 2000 | 104 | 59/45 | 4–16 | 10.6 | 13.5 | 22.1 | 7.6 | 46.2 | |
| Evangelista et al | 2000 | 50 | 33/17 | 5–21 | 8 | 4 | 76 | 12 | ||
| Lam and Tobias | 2001 | 55 | 28/27 | 6–20 | 12 | 15 | 4 | 32 | 4 | 30 |
| Sabri et al | 2003 | 132 | 21/23 | (12.10) | 33.1 | 36.1 | ||||
| Gastesi Larranaga et al | 2003 | 161 | ||||||||
| Yildirim et al | 2004 | 300 | 172/128 | 3–17 | 8 | 4.7 | 18.7 | 1.6 | 3 | 63.4 |
| Massin et al | 2004 | 168 | 133/104 | 3–15 | 5 | 4 | 9 | 64 | 13 | |
| Wojcicka-Urbanska et al | 2004 | 60 | (13.00) | 23 | 10 | 4 | 11 | 52 | ||
| Sadurska et al | 2005 | 132 | 22.7 | 11.4 | 25.8 | 1.5 | 6.8 | 46.2 | ||
| Lipsitz et al | 2005 | 27 | 15/12 | 8–17 | 59 | |||||
| Cagdas and Pac | 2009 | 120 | 66/54 | 5–16 | 42.5 | |||||
| Danduran et al | 2008 | 263 | 141/122 | 5–22 | ||||||
| Lin et al | 2008 | 103 | 64/39 | 4–17 | 2 | 5.8 | 2 | 6.7 | 24.3 | 59.2 |
| Hambrook et al | 2010 | 818 | 368/450 | 0–18 | 2.8 | 6.4 | 2.2 | 12.8 | 9.4 | 36.4 |
| Total | 5,222 | 13.5 | 14.63 | 20.30 | 22.00 | 11.84 | 44.35 |
The most recent study, which is also the largest one published (N = 818), was drawn from the 2002–2006 National Hospital Ambulatory Medical Care Survey (NHAMCS) in the United States. This included all emergency department visits with a main complaint of chest pain for individual’s aged less than 19 years. Chest pain was classified into 9 different groups ( Fig. 1 ). Chest pain not otherwise specified made up the majority (36.8%) of presentations, followed by infectious (21.1%), trauma-musculoskeletal (12.8%), respiratory (9.4%), other (8.2%), gastrointestinal (6.4%), cardiovascular (2.8%), psychiatric (2.2%), and hematologic (0.3%) presentations. This suggests that chest pain related to cardiovascular disease represents a very small proportion of all chest pain presentations to emergency departments.
However, if all studies conducted on pediatric chest pain are analyzed, there seems to be a significantly greater proportion of chest pain presentations associated with a cardiac cause (9.57%). The difference may be explained by some of these studies being taken from pediatric cardiology departments in which a diagnosis of cardiovascular disease is more likely to be found than in an emergency department setting. But if these data are taken as a whole, then it suggests that cardiac causes are more common than previously thought, relative to other types of chest pain. Moreover, the groupings of these chest pain types could also be an important factor, for example, with groups like other and chest pain not otherwise specified , a substantial proportion of patients have no known cause for their chest pain, at least in initial diagnostic workup in an emergency setting. It would seem worthwhile to follow up these patients over long periods to determine what subsequent diagnosis is applied to these cases and determine important clinical outcomes (eg, mortality, morbidity, repeat presentations).
A limited number of prospective studies have been conducted among pediatric patients, seeming to have similar problems to adult studies in terms of very small sample sizes, low follow-up rates, and short follow-up periods (3 years maximum). The largest of these studies consisted of 407 children at baseline, of whom, 149 were followed up for 6 months or more and 51 patients were followed up for 2 years of more. Patients had 3 repeat visits in the follow-up period, during which time, the initial diagnoses changed in just over a third of patients (34%), sometimes more than once (5%). Almost half the patients (43%) continued to experience intermittent or persistent chest pain.
The analysis of the studies in this systematic review based on the type of chest pain reported has generally consisted of 6 different groups, usually based on organ systems. These data suggest that idiopathic chest pain was most prevalent (35.62%), followed by musculoskeletal (19.75%), then psychological (16.31%), gastrointestinal (10.36%), cardiac (9.57%), and respiratory (8.39%) conditions as the primary cause of presentation ( Fig. 2 ).
