Chest Pain

Steven M. Selbst, MD

Chest Pain - BASICS

Chest Pain - description

Chest pain is a common pain syndrome in childhood (see table in “Etiology”: Most Common Causes of Pediatric Chest Pain). It is less common than abdominal pain and headache.

• Identify the rare child with a serious cause for chest pain (see tables in “Physical Exam” [Important Physical Findings on General Examination of Child with Chest Pain] and Etiology [Common Causes of Pediatric Chest Pain]):
  • Phase 1: Is the patient in acute distress? If so, begin emergency management and proceed rapidly to find the cause of pain.
  • Phase 2: For most stable children with chest pain, determine whether laboratory tests are needed to help identify the cause.
  • Phase 3: Treat specific conditions as appropriate. Begin analgesics, reassure the family, and arrange for follow-up care.

Chest Pain - epidemiology

Chest Pain - incidence

6/1,000 children who present to an urban emergency department complain of chest pain.

Chest Pain - etiology

Most common causes of pediatric chest pain

• Idiopathic
• Musculoskeletal:
  • Chest wall strain
  • Costochondritis
  • Direct trauma
• Respiratory conditions:
  • Asthma, cough, pneumonia
• Gastrointestinal problems:
  • Esophagitis, esophageal foreign body
  • Psychogenic—stress related
• Cardiac pathology

Chest Pain - associated conditions

• Asthma
• Cystic fibrosis
• Diabetes mellitus (long-standing)
• Hypertrophic cardiomyopathy
• Kawasaki disease
• Marfan syndrome
• Sickle cell disease
• Systemic lupus erythematosus

Chest Pain - DIAGNOSIS

Chest Pain - signs & symptoms

Hints for screening problem: Take a thorough history and perform a careful physical exam. Examine the chest last—do not focus only on this area. Use laboratory tests sparingly, only to confirm clinical suspicions.

Chest Pain - history

• How severe, how often is the pain?
  • Constant, frequent severe pain is more likely to be distressing, interruptive of daily activity. Serious etiology is not well correlated with frequency, severity of pain.
• What is the type of pain? Its location?
  • Burning pain is associated with esophagitis. Sharp, stabbing pain relieved by sitting up or leaning forward is typical of pericarditis. Young children do not describe or localize chest pain well.
• When was the onset of pain?
  • Acute pain (<48 hours) is more likely to have an organic cause. Chronic pain (>6 months) is more likely to be psychogenic, idiopathic. In an older child with sudden onset of pain, consider an arrhythmia, pneumothorax, or musculoskeletal injury. In a young child with sudden onset of pain, consider a foreign body (coin) in the esophagus, or injury.
• Is the pain induced by exercise?
  • Exercise-induced chest pain may be related to serious cardiac disease or asthma.
• Recent trauma, rough play or muscle overuse?
  • Musculoskeletal (chest wall) pain
• Eaten spicy foods? Taken tetracycline or other pills?
  • Esophagitis. Teens often take pills with little water and then lie down. The undissolved pill may lodge in the esophagus and cause pain.
• Recent use of cocaine?
  • Hypertension, tachycardia, myocardial ischemia, or pneumothorax
• Use of oral contraceptives or recent leg trauma?
  • Pulmonary embolism. This is very rare in the pediatric age group.
• Recent significant stress (e.g., move, death of loved one, serious illness)?
  • Psychogenic pain. We know children have headaches and abdominal pain related to stress. Chest pain may also relate to unusual stress.
• Associated complaints?
  • Fever may imply pneumonia, myocarditis, and pericarditis. Syncope, palpitations may imply cardiac arrhythmias or severe anemia. Joint pain, rash may relate chest pain to collagen vascular disease. Pain that resolves with parental attention may indicate an emotional cause.
• Positive familial history?
  • Hypertrophic cardiomyopathy is often familial. Those with this disorder may have familial history positive for sudden death. When there is a positive familial history of heart disease or chest pain, the parents may be unusually concerned about the symptom in a child. The child often has a nonorganic cause.
• Past medical history?
  • Previous Kawasaki disease, long-standing insulin-dependent diabetes mellitus, and sickle cell disease may have serious cardiac or pulmonary complications leading to chest pain. Marfan syndrome has increased risk for aortic dissection, pneumothorax. Asthma has increased risk for pneumonia, pneumothorax. Collagen vascular disease has increased risk for pleural effusion, pericarditis. Most underlying structural cardiac lesions rarely produce chest pain.

Chest Pain - physical exam

Important physical findings on general examination of child with chest pain

• Severe distress
• Chronically ill appearance
• Fever
• Skin rash or bruising
• Abdominal pathology
• Arthritis present
• Anxiety apparent

• Child is in significant distress:
  • Requires emergency care; stabilization. Consider pneumothorax, arrhythmia.
• Child appears chronically ill:
  • Chest pain may be found in serious illness such as malignancy (Hodgkin lymphoma) or systemic lupus erythematosus
• Fever:
  • Consider pneumonia, myocarditis, pericarditis
• Skin bruising present:
  • Chest pain may be related to unrecognized trauma
  • Osteomyelitis of the rib is a rare cause
• Abdominal pathology:
  • Pain may be referred to the chest
• Arthritis present:
  • Collagen vascular disease may manifest as pleural effusion, chest pain.
• Unusually anxious child:
  • Underlying stress may lead to pain.

Important physical findings on chest examination of child with chest pain

• Breast abnormality
• Subcutaneous emphysema
• Heart murmur, rub, arrhythmia
• Chest wall tenderness

• Breast enlargement, asymmetry, tenderness:
  • Physiologic breast changes in young teens may be painful. Consider pregnancy in teenage girls.
• Decreased breath sounds, wheezing:
  • May suggest pneumonia, asthma with overuse of chest wall muscles
• Subcutaneous emphysema palpable on chest or neck:
  • Pneumothorax, pneumomediastinum
• Heart murmur, rub, arrhythmia:
  • Congenital heart disease, cardiac infection such as myocarditis, pericarditis, supraventricular tachycardia, ventricular tachycardia.
• Tenderness of chest wall, costochondral junctions:
  • Musculoskeletal pain

Factors that make this an emergency include:

• Pneumothorax: May present with severe sudden chest pain, respiratory distress, cyanosis, hypotension
• Cardiac arrhythmia: Ventricular tachycardia or supraventricular tachycardia in an older child may progress to heart failure or a lethal rhythm.
• Cocaine intoxication: May present with pneumothorax, cardiac arrhythmia, hypertension
• Direct chest trauma: May lead to cardiac contusion and arrhythmia
• Caustic ingestions or esophageal foreign bodies require prompt attention.

Chest Pain - tests

Chest Pain - lab

• EKG:
  • Obtain if history suggests cardiac pathology (e.g., acute onset of pain, pain on exertion, pain associated with syncope, dizziness, palpitations, history of congenital heart disease, serious associated medical problems [Kawasaki disease, diabetes mellitus], use of cocaine)
  • Obtain also if physical exam is abnormal. For instance: Respiratory distress, cardiac abnormality, fever, significant trauma
• Holter monitor:
  • Arrange for this study if cardiac arrhythmia suspected. Electrocardiogram may fail to detect intermittent arrhythmia.
• Exercise stress test, pulmonary function tests:
  • Obtain if pain induced by exertion
• Drug screen:
  • Obtain if cocaine use suspected

Chest Pain - imaging

Chest radiograph:

• Same as for EKG
• Obtain also if history suggests cardiac or pulmonary pathology, tumor, Marfan syndrome, or foreign body (coin ingestion)
• Obtain also if physical examination suggests decreased breath sounds, or palpation of subcutaneous air

Chest Pain - differencial diagnosis

• Musculoskeletal disorders:
  • Chest wall strain
  • Costochondritis
  • Direct chest trauma
  • Slipping rib syndrome
• Cardiac pathology:
  • Arrhythmia (supraventricular tachycardia, premature ventricular contractions)
  • Coronary artery anomalies
  • Coronary artery aneurysms (Kawasaki disease)
  • Infections (myocarditis, pericarditis)
  • Myocardial infarction/ischemia
  • Structural abnormalities: Aortic stenosis, hypertrophic cardiomyopathy, pulmonic stenosis, mitral valve prolapse, severe coarctation of the aorta
• GI disorders:
  • Caustic ingestions
  • Esophageal foreign bodies
  • Esophagitis (sometimes tetracycline, “pill,” induced)
• Psychogenic causes:
  • Anxiety
  • Hyperventilation
• Respiratory disorders:
  • Asthma
  • Cough (prolonged)
  • Pleural effusion
  • Pneumonia
  • Pneumothorax: Spontaneous, trauma related, drug related (cocaine)
  • Pneumomediastinum
  • Pulmonary embolism
• Miscellaneous:
  • Breast mass
  • Cigarette smoke
  • Pleurodynia
  • Precordial catch syndrome
  • Shingles
  • Sickle cell crises
  • Thoracic tumor

Chest Pain - TREATMENT

Chest Pain - general measures

Clinical pearls:

• Chest pain in children is rarely related to cardiac pathology: Not all children with chest pain have a benign etiology; pain associated with exertion, syncope, dizziness is concerning for heart disease; if the child is febrile, consider pneumonia or viral myocarditis.
• Treat specific cause when found.
• OTC analgesics (acetaminophen, ibuprofen) suffice for most pain.
• Antacids may be diagnostic and therapeutic for esophagitis pain.
• Rest, heat, relaxation techniques may be useful.
• Avoid expensive, invasive laboratory studies with chronic pain and normal physical examination, benign history.

Chest Pain - FOLLOW UP

Chest Pain - disposition

Chest Pain - issues for referral

• Acute distress
• Significant trauma
• History of heart disease or related serious medical problem
• Pain with exercise, syncope, palpitations, dizziness
• Serious emotional disturbance
• Esophageal foreign body, caustic ingestion
• Pneumothorax, pleural effusion

Chest Pain - prognosis

40% will have continued chest pain for 6–24 months. Most have an excellent prognosis.

Chest Pain - bibliography

1. Brumund MR, Strong WB. Murmurs, fainting, chest pain: Time for a cardiology referral? Contemp Pedatr. 2002;19:155–166.
2. Gumbiner CH. Precordial catch syndrome. South Med J. 2003;96:38–41.
3. Lam JC, Tobias JD. Follow-up survey of children and adolescents with chest pain. South Med J. 2001;94:921–924.
4. Lipsitz JD, Masia-Warner C, Apfel H, et al. Anxiety and depressive symptoms and anxiety sensitivity in youngsters with noncardiac chest pain and benign heart murmurs. Journ Pediatr Psychol. 2004;29:607–612.
5. Madhok AB, Boxer R, Green S. An adolescent with chest pain-sequela of Kawasaki disease. Ped Emerg Care. 2004;20:765–768.
6. Massin MM, Bourguignont A, Coremans C, et al. Chest pain in pediatric patients presenting to an emergency department or to a cardiac clinic. Clin Pediatr. 2004;43:231–238.
7. Owens TR. Chest pain in the adolescent. Adolesc Med. 2001;12:95–104.
8. Selbst SM, Ruddy RM, Clark BJ, et al. Pediatric chest pain: A prospective study. Pediatrics. 1988; 82:319–323.
9. Washington RL. Sudden deaths in adolescent athletes caused by cardiac conditions. Pediatr Ann. 2003;32:751–756.

Chest Pain - CODES

Chest Pain - icd9

• 786.5 Chest pain
• 786.50 Chest pain, central
• 786.51 Chest pain, midsternal
• 786.51 Chest pain, substernal
• 786.52 Chest pain, wall (anterior)
• 786.59 Chest pain, atypical
• 786.59 Chest pain, musculoskeletal
• 786.59 Chest pain, noncardiac

Chest Pain - FAQ

• Q: How common is chest pain in children?
• A: Chest pain is a common pain syndrome reported in 6/1,000 children who present to an urban emergency department. The complaint is less common than abdominal pain or headache. Although children of all ages may complain of chest pain, the mean age is ~12 years.
• Q: Is follow-up important?
• A: Yes. Serious pathology is unlikely to be found if not diagnosed initially. However, watch for signs of exercise-induced asthma or for emotional problems that were not obvious initially. Ensure that the child returns to normal activity when appropriate.
• Q: What is the prognosis for most children with chest pain?
• A: Most children with chest pain have an excellent prognosis. ~40% of children with chest pain will have continued symptoms for 6–24 months.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

Other Book Chapters Related to Chest pain

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

Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Williams & Wilkins.

More About Causes of Chest pain

• Back to symptom: Chest pain: Introduction (review 942 causes)
• Next Book Extract About Chest pain: Medications causing Chest pain
• All Book Extracts: All Online Book Extracts for Chest pain

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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