Chapter 6: Chest Pain

• Children with chest pain present to the emergency department (ED) at a rate of 3 to 6 for every 1000 patient visits.

• In the majority of cases, the etiology of the chest pain is benign.

• The differential diagnosis is extensive; however, meticulous history and physical examination usually obviates the need for investigations.

Chest pain is a worrisome symptom that often causes parents to bring their child to the emergency department (ED) for evaluation. The rate of pediatric patients presenting to the ED with a complaint of chest pain is 3 to 6 for every 1000 patient visits.^1,2

In the majority of cases, the etiology of the chest pain is benign, but symptoms are distressing enough to cause 27% to 30% of children to miss school.^2,3

The clinical presentation of the pediatric patient with chest pain varies greatly. The average age of presentation is 10 to 12 years, with an equal distribution between sexes.^1–4 Younger children are more likely to have a cardiorespiratory source for their chest pain, whereas the chest pain of an adolescent patient is more likely to be of psychogenic origin.^1,3

The duration of the chest pain in the majority of patients is either acute or subacute in onset.^1,3 Patients that present with a complaint of chronic chest pain (>6 months duration) usually have idiopathic or psychogenic chest pain.^3,4

Children often have difficulty localizing and qualifying their pain. In instances where the child is able to indicate a location for his or her chest pain (e.g., right-sided, left-sided, and sternal), no specific relationship to a particular diagnosis or diagnostic category has been found.^1–3 The description of the pain (e.g., sharp, dull, and aching) also shows no relationship to the actual diagnosis.³

The differential diagnosis for pediatric chest pain is extensive (Table 6-1).

Cardiac

A cardiac cause for pediatric chest pain is found in 4% to 5% of cases presenting to the ED.^1,3 Myocardial infarction is rare in the pediatric population, but has been reported in the literature in previously healthy adolescents.⁵ These patients usually present with the classic severe, substernal chest pain with radiation to the left arm or jaw; however, it is important to note that the location and severity of a child's chest pain is not specific to myocardial infarction or a cardiac etiology.^1–3,5 Patients are at greater risk for myocardial ischemia if they have a history of congenital heart disease, acquired heart disease (e.g., Kawasaki disease), or drug abuse (e.g., cocaine), thus a thorough history and physical examination is imperative.

Pericarditis and myocarditis are cardiac diseases that cause chest pain. Both conditions can present with fever and chest pain, although myocarditis usually has a more insidious onset. Pericarditis usually presents with sharp, substernal chest pain that is alleviated by leaning forward. On physical examination, the patient classically has distant heart sounds, a friction rub, and signs of congestive heart failure (CHF). Myocarditis patients often have vague symptoms including chest pain, dyspnea, dizziness, nausea, vomiting, and fatigue. Physical examination usually reveals a gallop, signs of CHF, and tachycardia unresponsive to fluids. A concerning history and physical examination should prompt the practitioner to consider myocarditis and pericarditis.

Structural abnormalities of the heart and vessels can cause chest pain. Hypertrophic cardiomyopathy patients usually give a history of increased chest pain with exertion. Aortic stenosis, pulmonary stenosis, abnormal coronary arteries, and mitral valve prolapse, depending on the severity, can lead to ischemia of the heart and papillary muscles. History and physical examination of these patients typically reveal a heart murmur associated with the lesion.

Arrhythmias can cause chest pain in children. Premature ventricular tachycardia can present as a fleeting, sharp pain, or palpitations. Supraventricular tachycardia (SVT) is usually described as a rapid heartbeat. Physical examination should cue the physician to the possibility of SVT.

Respiratory

In children, a pulmonary etiology for chest pain was found in 12.5% to 19% of cases.^1,2,4 Patients presenting with a history of asthma or reactive airway disease should prompt the physician to assess for the possibility of chest pain secondary to an asthma exacerbation. Bronchospasm and persistent coughing can lead to excessive use of the chest wall muscles and is a common cause of chest pain.

Pneumonia with or without pleural effusion can also cause chest pain. Presenting signs and symptoms would usually include fever, tachypnea, and upper respiratory symptoms. Physical examination may reveal decreased breath sounds or crackles.

Patients who report acute pain and subsequent respiratory distress should raise suspicion for a spontaneous pneumothorax or pneumomediastinum. The typical patient with a spontaneous pneumothorax is a tall thin boy presenting with an abrupt onset of unilateral chest pain.⁶ Patients with asthma, Marfan's syndrome, or cystic fibrosis are at increased risk for developing pneumothoraces. Physical examination may reveal decreased breath sounds on the affected side and crepitus depending on the extent of the pathology. A hemothorax should also be considered if there is a history of trauma.

Pulmonary embolism is rare in pediatrics, but should be considered in adolescents who complain of dyspnea, pleuritic chest pain, hemoptysis, and low-grade fever. Risk factors for a pulmonary embolism are the use of birth-control pills, recent abortion, prolonged immobility, inherited hypercoagulable disorders, indwelling central lines, and major trauma, particularly to the lower extremities.

Gastrointestinal

Gastrointestinal (GI) causes for pediatric chest pain make up 3% to 4% of ED visits.^1,3 Gastroesophageal reflux disease causes a burning, substernal pain. Epigastric tenderness on physical examination and the association of the pain with food is suggestive of a GI origin.^1,7

Children who have ingested a foreign body that is lodged in the esophagus can have chest pain. Patients may have dysphagia depending on the location of the foreign body.

Musculoskeletal

A musculoskeletal etiology for chest pain is found in 32.5% to 43% of ED visits.^2,4 Trauma can cause fractures and contusions that may result in chest pain. Overuse or overexertion of the chest wall muscles may cause muscle strain.

Costochondritis is a common condition recognized by the practitioner when chest pain is elicited by palpating the costochondral joints. The etiology of costochondritis is unknown, but it is considered to be a benign, inflammatory condition. A similar disease, Tietze's syndrome, also occurs at the costochondral junctions, but has the associated findings of swelling, redness, and warmth. Like costochondritis, Tietze's syndrome is thought to be a self-limited inflammatory condition.

Slipping rib syndrome usually occurs at the false or floating ribs. The patient usually describes a sharp, intermittent pain that lasts a few minutes and settles to a dull ache. There may be a history of trauma and aggravation with movement. The etiology of the pain is thought to result from the anterior end of the rib, slipping out of place and aggravating the adjacent intercostal nerve. The “hooking maneuver” can be used to help diagnose this condition. The patient is instructed to lie on the unaffected side and the practitioner reaches under the lower costal margin and pulls the rib anteriorly. A positive test results in the reproduction of the patient's pain and a click sensation.

Precordial catch syndrome, or Texidor's twinge, is a benign condition that causes a brief, sharp pain to the left chest without radiation. The pain may occur with exercise or when the patient is at rest in a slouched position. The etiology is unclear, but is thought to occur from the parietal pleura, intercostal nerves, or from the stretching of the supporting ligaments of the heart.

Chest wall pain that follows a dermatome should raise the physician's suspicion for a herpes zoster infection. This is not a musculoskeletal condition, but deserves mentioning as the patient's pain may precede the skin lesions.

The diagnostic evaluation of children presenting with chest pain includes a thorough history and physical examination. Further diagnostic studies may be needed (Fig. 6-1).

A chest radiograph can be a useful diagnostic study. It can reveal a cardiac process leading to the appearance of an enlarged heart or pulmonary edema resulting from CHF. A pulmonary etiology such as pneumonia, pleural effusion, pneumothorax (Fig. 6-2), hemothorax, and pneumomediastinum can also be found. A radiopaque esophageal foreign body will be visible. Echocardiogram can detect pericardial effusion and abnormal wall motion.

Most musculoskeletal causes of chest pain would not have noticeable changes on a chest film, except for a rib or sternum fracture. Chest x-rays are not required in every pediatric patient with chest pain, but should be ordered when there is suspicion for one of the aforementioned conditions.^1–3

Patients with a concerning history or physical examination merit evaluation with an ECG. Common ECG findings with childhood myocardial infarction include Q waves greater than 35 ms, ST segment elevation greater than or equal to 2 mm, and prolonged calculated QT interval greater than 440 ms.⁸ An ECG can alert the physician to conduction and/or structural heart defect. Myocardial and pericardial disease can also be suggested by an ECG.

Laboratory studies can assist with the identification of certain causes of chest pain. An elevated white blood cell count may indicate an infectious etiology, such as pneumonia. A D-dimer can help rule out the likelihood of a pulmonary embolism in low to intermediate risk patients.⁹

Troponin levels can be utilized in children to diagnose myocardial necrosis.^5,10–12

The management of patients with chest pain depends on the underlying cause. Appropriate therapy should be initiated in the ED with specialty consultation and referrals as needed. Cardiac causes of chest pain generally require cardiology consultation. Depending on the clinical severity of the patient and diagnosis, the patient may require immediate consultation or outpatient referral.

Pulmonary causes such as asthma and pneumonia should be treated with standard medications. Pneumothorax and hemothorax may require emergent intervention with a needle decompression or chest tube placement, but that would depend on the size of the lesion and patient status. Patients with a pulmonary embolism require admission and anticoagulation therapy similar to adults.

GI causes of chest pain can usually be treated as an outpatient. Patients with gastroesophageal reflux disease can have medication therapy initiated and subsequent follow-up with either a gastroenterologist or pediatrician. Patients with an esophageal foreign body will usually be able to pass it through the GI tract, but if concerned because of the size or other factors, a consultation to remove the foreign body can be made.

Musculoskeletal causes of chest pain can generally be treated with rest and nonsteroidal anti-inflammatory agents. The slipping rib syndrome can be treated with education and avoidance of the offending movements. Local nerve blocks and corticosteroid injections are sometimes necessary. A surgical alternative is to have the anterior end of the rib and costal cartilage removed, but this is usually done after failure of medical management. Precordial catch syndrome is a self-limiting condition that requires only education and supportive care.

Psychogenic causes of chest pain usually require outpatient follow-up by the patient's pediatrician or psychiatrist. If the anxiety, depression, or stress is severe, psychiatric consultation and medical management should be considered.

In cases of idiopathic chest pain, no specific therapy is needed, but follow-up is essential. Emergency follow-up recommendations should also be given to the patient and family.