Basics
Description
Chest pain is a common pain syndrome in childhood. It is less common than abdominal pain and headache. Cardiac disease is an uncommon etiology. Musculoskeletal cause is most common. Boys and girls are equally affected. Etiology is often unclear (idiopathic).
Commonly Associated Conditions
- Asthma
- Cystic fibrosis
- Diabetes mellitus (long-standing)
- Hypertrophic cardiomyopathy
- Kawasaki disease
- Marfan syndrome
- Sickle cell disease
- Systemic lupus erythematosus
Diagnosis
Differential 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: hypertrophic cardiomyopathy
- GI disorders
- Caustic ingestions
- Esophageal foreign bodies
- Esophagitis (sometimes tetracycline or "pill" induced)
- Psychogenic causes
- Anxiety/stress
- 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-acute chest syndrome
- Thoracic tumor
Approach to Patient
Identify the rare child with a serious cause for chest pain (see discussion in "Physical Exam"-[Important Physical Findings on General Examination of Child with 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.
Hints for Screening Problems
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.
History
- Question: How severe, how often is the pain?
- Significance: Constant, frequent severe pain is more likely to be distressing and interruptive of daily activity. Serious etiology is not well correlated with frequency and severity of pain.
- Question: What is the type of pain? Where is its location?
- Significance: 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.
- Question: When was the onset of pain?
- Significance: Acute pain (<48 hours) is more likely to have an organic cause. Chronic pain (>6 months) is more likely to be psychogenic or 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.
- Question: Is the pain induced by exercise?
- Significance: Exercise-induced chest pain may be related to serious cardiac disease or asthma.
- Question: Recent trauma, rough play, or muscle overuse?
- Significance: Musculoskeletal (chest wall) pain
- Question: Eaten spicy foods? Taken tetracycline or other pills?
- Significance: Esophagitis. Teens often take pills with little water and then lie down. The undissolved pill may lodge in the esophagus and cause pain.
- Question: Recent use of "street drugs" such as cocaine?
- Significance: Hypertension, tachycardia, myocardial ischemia, or pneumothorax
- Question: Use of oral contraceptives, clotting disorder, or recent leg trauma?
- Significance: Pulmonary embolism. This is rare in the pediatric age group.
- Question: Recent significant stress (e.g., move, death of loved one, serious illness)?
- Significance: Psychogenic pain. Children may have headaches and abdominal pain related to stress. Chest pain may also relate to unusual stress.
- Question: Associated complaints?
- Significance: Fever may imply pneumonia (common), myocarditis, and pericarditis (less common but serious). Syncope and palpitations may imply cardiac arrhythmias or severe anemia. Joint pain or rash may relate chest pain to collagen vascular disease. Pain that resolves with parental attention may indicate an emotional cause.
- Question: Positive familial history?
- Significance: 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.
- Question: Past medical history?
- Significance: 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 and pneumothorax. Asthma has increased risk for pneumonia and pneumothorax. Collagen vascular disease has increased risk for pleural effusion and pericarditis. Most underlying structural cardiac lesions rarely produce chest pain. Hypertrophic cardiomyopathy is a high-risk situation.
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
- Finding: Child is in significant distress?
- Significance: Requires emergency care; stabilization. Consider pneumothorax or arrhythmia.
- Finding: Child appears chronically ill?
- Significance: Chest pain may be found in serious illnesses such as malignancy (Hodgkin lymphoma) or systemic lupus erythematosus.
- Finding: Fever?
- Significance: Consider pneumonia, myocarditis, or pericarditis.
- Finding: Skin bruising present?
- Significance: Chest pain may be related to unrecognized trauma. Osteomyelitis of the rib is a rare cause.
- Finding: Abdominal pathology?
- Significance: Pain may be referred to the chest.
- Finding: Arthritis present?
- Significance: Collagen vascular disease may manifest as pleural effusion or chest pain.
- Finding: Unusually anxious child?
- Significance: 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
- Finding: Breast enlargement, asymmetry, tenderness?
- Significance: Physiologic breast changes in young teens may be painful. Consider pregnancy in teenage girls.
- Finding: Decreased breath sounds, wheezing?
- Significance: May suggest pneumonia, asthma with overuse of chest wall muscles
- Finding: Subcutaneous emphysema palpable on chest or neck?
- Significance: Pneumothorax, pneumomediastinum
- Finding: Heart murmur, rub, arrhythmia?
- Significance: Congenital heart disease, hypertrophic cardiomyopathy, cardiac infections such as myocarditis, pericarditis, supraventricular tachycardia, ventricular tachycardia
- Finding: Tenderness of chest wall, costochondral junctions?
- Significance: Musculoskeletal pain
Alert
Factors that make this an emergency include the following:
- 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.
Diagnostic Tests & Interpretation
- Test: EKG
- Significance
- 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
- Test: Holter monitor
- Significance: Arrange for this study if cardiac arrhythmia is suspected. EKG may fail to detect intermittent arrhythmia.
- Test: Exercise stress test
- Significance: Obtain if pain is induced by exertion. Usefulness is debated but may identify cardiac disease or asthma.
- Test: Drug screen
- Significance: Obtain if cocaine use is suspected.
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 exam suggests decreased breath sounds or palpation of subcutaneous air.
Treatment
Additional Treatment
General Measures
Chest pain in children is rarely related to cardiac pathology. However, 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 15 mg/kg/dose, ibuprofen 10 mg/kg/dose) suffice for most pain. Antacids may be diagnostic and therapeutic for esophagitis pain. Rest, heat, and relaxation techniques may be useful. Avoid expensive, invasive laboratory studies with chronic pain and normal physical exam or benign history.
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
- Abnormal heart (or sometimes lung) exam
- Abnormal EKG
Ongoing Care
Prognosis
40% will have continued chest pain for 6-24 months. Follow-up care is important. 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. Encourage return to normal activity if evaluation is negative. Most have an excellent prognosis.
Additional Reading
- Danduran MJ, Earing MG, Sheridan DC, et al. Chest pain: characteristics of children/adolescents. Pediatr Cardiol. 2008;29(4):775-781. [View Abstract]
- Drossner DM, Hirsh DA, Sturm JJ, et al. Cardiac disease in pediatric patients presenting to a pediatric ED with chest pain. Am J Emerg Med. 2011;29(6):632-638. [View Abstract]
- Saleeb SF, Li WY, Warren SZ, et al. Effectiveness of screening for life-threatening chest pain in children. Pediatrics. 2011;128(5):e1062-e1068. [View Abstract]
- Selbst SM. Approach to the child with chest pain. Pediatr Clin North Am. 2010;57(6):1221-1234. [View Abstract]
- Selbst SM, Palermo R, Durani Y, et al. Adolescent chest pain-is it the heart? Clin Ped Emerg Med. 2011;12:289-300.
Codes
ICD09
- 786.5 Chest pain, unspecified
- 786.59 Other chest pain
- 493.9 Asthma, unspecified type, without mention of status asthmaticus
- 848.8 Other specified sites of sprains and strains
- 733.6 Tietze's disease
- 277 Cystic fibrosis without mention of meconium ileus
ICD10
- R07.9 Chest pain, unspecified
- R07.89 Other chest pain
- J45.909 Unspecified asthma, uncomplicated
- S29.011A Strain of muscle and tendon of front wall of thorax, init
- E84.9 Cystic fibrosis, unspecified
- M94.0 Chondrocostal junction syndrome [Tietze]
SNOMED
- 29857009 Chest pain (finding)
- 281245003 Musculoskeletal chest pain (finding)
- 195967001 Asthma (disorder)
- 430894003 Strain of muscle of chest wall (disorder)
- 64109004 Costalchondritis (disorder)
- 190905008 Cystic fibrosis (disorder)
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 about 12 years.
- Q: Which features in the history are worrisome?
- A: Acute onset of pain, it occurs with exercise, associated syncope, dizziness or palpitations, heart disease or chronic conditions that can affect the heart, trauma, fever, drug use (e.g., cocaine)
- Q: Which findings on physical exam are most worrisome?
- A: Respiratory distress, decreased/abnormal breath sounds, cardiac abnormality, fever, trauma, subcutaneous air, Marfan features
- Q: Which children with chest pain do not need extensive evaluation with laboratory studies?
- A: Those with chronic pain (>6 months), and none of the worrisome features mentioned earlier. Individualized management-analgesics, reassurance, and follow-up usually suffice.
- Q: Why should clinicians be concerned about chest pain in children?
- A: Heart disease is an uncommon cause, but serious pathology is found in some cases. Parental fears must be addressed.