Chest Pain in Children
Young children are more likely to have a cardiorespiratory cause of their pain, such as cough, asthma, pneumonia, or heart disease; adolescents are more likely to have pain associated with a psychogenic disturbance.
I. Differential diagnosis of chest pain in children
Cardiac disease is a rare cause of chest pain in children. Some children will have a pansystolic, continuous or mitral regurgitation murmur or gallop rhythm that suggests myocardial dysfunction.
Arrhythmias may cause palpitations or abnormalities on cardiac examination.Supraventricular tachycardia is the most common arrhythmia, but premature ventricular beats or tachycardia also can cause episodes of brief sharp chest pain.
Hypertrophic obstructive cardiomyopathy is an autosomal dominant structural disorder. Therefore, there often is a family history of the condition. Children may have a murmur that maybe audible when standing.
Mitral valve prolapse may cause chest pain secondary to papillary muscle or endocardial ischemia. A midsystolic click and a late systolic murmur may be detected.
Cardiac infections are uncommon causes of pediatric chest pain :
- a. Pericarditis presents with sharp, stabbing pain that improves when the patient sits
up and leans forward.
- b. Myocarditis presents as mild pain that has been present for several days. After a fewdays of fever,vomiting and lightheadedness, the patient may develop pain or shortness of breath on exertion.
- c. Chest radiographywill show cardiomegaly in both ofthese infections,and the electrocardiogram will be abnormal. An echocardiogram will confirm the diagnosis.
One of the most common diagnoses in children who have chest discomfort is Musculoskeletal pain. Children frequently strain chest wall muscles while exercising.
Costochondritis is common in children, and it is characterized by tenderness over the costochondral junctions. The pain is sharp and exaggerated by physical activity or breathing.
Severe cough, asthma, or pneumonia may cause chest pain because of overuse of chest wall muscles. Crackles, wheezes, tachypnea, or decreased breath sounds are present.
Exercise-induced asthma may cause chest pain, which can be confirmed with a treadmill test.
Spontaneous pneumothorax or pneumomediastinum may occasionally cause chest pain with respiratory distress. Children with asthma, cystic fibrosis or Marfan syndrome are at high risk. Signs include respiratory distress, decreased breath sounds on the affected side, and palpable subcutaneous air.
Pulmonary embolism is extremely rare in pediatric patients, but it should be considered in the adolescent girl who has dyspnea, fever, pleuritic pain, cough, and hemoptysis. Oral contraceptives or recent abortion increase the risk. Young males who have had recent leg trauma also are at risk.
Reflux esophagitis often causes chest pain, which is described as burning, substernal, and worsened by reclining or eating spicy foods. This condition is confirmed with a therapeutic trial of antacids.
Foreign body ingestion may cause chest pain when the object lodges in the esophagus. A radiograph confirms the diagnosis.
Miscellaneous causes of pediatric chest pain
II. Clinical evaluation of chest pain
- Sickle cell disease may cause an acute chest syndrome.
- Marfan syndrome may cause chest pain and fatal abdominal aortic aneurysm dissection.
- Collagen vascular disorders may cause chest pain and pleural effusions.
- Shingles may cause chest pain that precedes or occurs simultaneously with the rash.
- Coxsackievirus infection maylead to pleurodynia with paroxysms of sharp chest pain.
- Breast tenderness during puberty or early breast changes of pregnancy may present as chest pain.
- Idiopathic chest pain. No diagnosis can be determined in 20-45% of cases of pediatric chest pain.
A history and physical examination will reveal the etiology of chest pain in most cases. The history may reveal asthma, previous heart disease, or Kawasaki disease. Family history may reveal familial hypertrophic obstructive cardiomyopathy.
The frequency and severity of the pain and whether the pain interrupts the child's daily activity should be determined. Pain that wakes the child from sleep is more likely to be related to an organic etiology.
Burning pain in the sternal area suggests esophagitis. Sharp stabbing pain that is relieved by sitting up and leaning forward suggests pericarditis in a febrile child.
Mode of onset of pain. Acute onsetofpain is more likely to represent an organic etiology. Chronic pain is much more likely to have a idiopathic or psychogenic origin.
Trauma, muscle strain or choking on a foreign body should be sought.
Exercise-induced chest pain may be caused by cardiac disease or exercise-induced asthma.
Syncope, fever or palpitations associated with chest pain are signs of an organic etiology.
Joint pain, rash or fever may be suggested by the presence ofcollagen vascular disease.
Stressful conditions at home or school should be sought.
Substance abuse (cocaine) ororalcontraceptives should be sought in adolescents.
Severe distress warrants immediate treatment for life-threatening conditions,such as pneumothorax.
Hyperventilation may be distinguished from respiratory distress by the absence of cyanosis or nasal flaring.
Pallor or poor growth maysuggest a malignancy or collagen vascular disease.
Abdominal tenderness maysuggest abdominal pain that is referred to the chest.
Rales, wheezes, decreased breath sounds, murmurs, rubs, muffled heart sounds or arrhythmias suggesta cardiopulmonarypathology.
The chest wall should be evaluated for bruises (trauma), tenderness (musculoskeletal pain), or subcutaneous air (pneumothoraxorpneumomediastinum).
III. Laboratory evaluation
A chest radiograph can be if the patient has fever, respiratory distress, or abnormal breath sounds. Fever and cardiomegalysuggests pericarditis or myocarditis.
Electrocardiography is recommended if the pain was acute in onset or if there is an abnormal cardiac examination (unexplained tachycardia, arrhythmia, murmur, rub, or click).
Exercise stress testing or pulmonaryfunction testing is appropriate for evaluation of cardiac disease or asthma.
Children with chronic pain, a normal physical examination, and no history suggestive of cardiac or pulmonary disease do not require laboratory studies.
Blood counts and sedimentation rates are of value ifcollagen vascular disease, infection, or malignancy is suspected.
Drug screening may be indicated in the older child who has acute pain associated with anxiety, tachycardia, hypertension, or shortness of breath.
IV. Management of pediatric chest pain
Emergency department referral is necessary if the child is in severe distress or has a history of significant trauma.
Referral to a cardiologist is recommended for children with known or suspected heart disease, syncope, palpitations, or pain on exertion.
Musculoskeletal, psychogenic or idiopathic pain usually will respond to reassurance,analgesics, rest, and application of a heating pad. If esophagitis is suspected, a trial of antacids may be beneficial.