Chest Pain

Chest pain is a frequent complaint in pediatrics, especially in the adolescent age group. Although rarely cardiac in etiology, this often represents the patient's/family's greatest fear. A careful history and physical exam, with attention to the needs of the patient/family and appropriate reassurance, are often all that are required.

Differential Diagnosis

• Musculoskeletal
  –Sharp, stabbing pain that is usually very well localized, often worsened by deep breath or cough
  –Costochondritis: Tender parasternal pain at insertion of ribs into cartilage en route to sternum; increases with palpation or mild chest compression (possibly postviral)
  –Injury to chest wall

• Pulmonary
  –Very common cause, usually associated with respiratory symptoms: Shortness of breath, cough, exercise intolerance
  –Asthma (most common), often only EIA; may have personal/family history of atopy (asthma, eczema, seasonal allergies); shortness of breath is usually primary complaint, with feeling of chest tightness/pain as a secondary symptom
  –Pleuritic chest pain: Sharp, stabbing pain with deep breaths, indicates pleural space inflammation, probably postinfectious (especially viral)
  –Pneumonia: Chest pain secondary to cough or pleural involvement
  –Pneumothorax can occur spontaneously, especially in tall, thin athletes

• Gastrointestinal
  –GERD and PUD: Burning, substernal pain with eating, worse at night
  –Rarely pancreatitis (with back pain too), cholecystitis, hiatal hernia, hepatitis

• Cardiac: Rare in children
  –Precordial catch syndrome: Sharp, brief (seconds) chest pain usually associated with rising from lying or sitting; unclear etiology, but of no significance
  –Pericarditis: Inflammation of the pericardium; often postviral, may represent connective tissue/autoimmune, cancer, bacterial infection (very ill appearing with fever), or post-cardiac surgery; patients often lean forward to decrease the pain
  –MI (rare): Congenital coronary anomaly, post-Kawasaki, cocaine use, hypertrophic cardiomyopathy
  –Aortic dissection: Consider if features or history of Marfan syndrome is present

Workup and Diagnosis

• History
  –Activity at onset, (chest pain with exercise is a red flag!), precipitating/relieving factors, quality of pain (sharp vs dull)
  –Associated symptoms (shortness of breath, diaphoresis, cough/wheeze, nausea/vomiting), recent illness, response to eating, sleeping, different foods (caffeine, chocolate, spicy, or high-fat foods)
  –Personal/family history of asthma, allergies, eczema
  –Recent diagnosis of heart disease or death in a family member often generates fear in the patient or parent, prompting the evaluation of chest pain
  –Social history: Recent life stressors (school problems, family discord, etc.); drug use, especially cocaine
• Physical exam
  –Reproducible with palpation likely musculoskeletal
  –Chest exam: Wheezing, rales, crepitus
  –Cardiac exam: Usually normal, even with cardiac causes; pericarditis is associated with rub
• Chest X-ray for infiltrates, pneumonia, pneumothorax
• ECG and cardiac enzymes are rarely required but relatively inexpensive and readily available, and can rule out MI and provide reassurance for families
• Cardiac stress test
  –Continuous ECG monitoring while the patient exercises to evaluate for coronary insufficiency
  –Used for patients with exercise-induced chest pain and/or coronary abnormalities

Treatment

• Most patients/families with chest pain simply want reassurance that symptoms are not cardiac in origin
• A careful history and physical exam are most important; however, a normal CXR and ECG provide therapeutic reassurance to the patient/family
• Further cardiology consultation is rarely required but should be considered with patients experiencing chest pain with exercise, a history of Kawasaki disease, Marfan syndrome (this is an emergency), and for those patients with persistent chest pain
• Costochondritis: Treated with NSAIDs until resolved
• Pericarditis: Treated with aspirin or NSAIDs; requires cardiology follow-up until resolved, rarely requires pericardiocentesis
• Appropriate therapy of identified pulmonary, gastrointestinal, or musculoskeletal problems

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Chest discomfort

Read excerpts from these other book chapters related to Chest discomfort:

Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Chest discomfort

• Back to symptom: Chest discomfort: Introduction (review 29 causes)
• Next Book Extract About Chest discomfort: CHEST PAIN (Differential Diagnosis in Primary Care)
• All Book Extracts: All Online Book Extracts for Chest discomfort

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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