Abstract
Pediatric chest pain is a common complaint for seeking medical care. Though most of the etiologies that lead to chest pain in children are benign, the complaint itself creates significant anxiety for parents/caregivers. History and physical examination can help a clinician to rule out serious etiologies of chest pain in children, thus limiting the need for extensive workup.
Keywords
pediatric chest pain
A 14-year-old-male presents to an urgent care facility for new onset intermittent chest pain with onset over a few weeks since he has started to play competitive basketball. Pain is exertional, retrosternal, no radiation, squeezing pressure like, with resolution after rest. On the day of presentation, he has a similar episode but with dizziness and near-syncope. He has a heart rate of 85 beats per minute, respiratory rate of 25 breaths per minute, and blood pressure of 130/75 mm Hg. He has a normal respiratory and chest wall exam. He has a systolic ejection (crescendo–decrescendo) murmur between the apex of the heart and left sternal border that becomes more prominent with standing.
1
What are the concerning features of this patient’s chest pain presented in the scenario?
Exertional chest pain with dizziness and/or syncope is concerning for a cardiac pathology. The characteristic of his murmur is consistent with possible hypertrophic cardiomyopathy. His electrocardiogram (ECG) is shown in Fig. 18.1 . He will be best managed by an urgent referral to a pediatric cardiologist while refraining him from any exertional activity.
4
What are the components of a good history and physical examination in assessment of a pediatric patient with chest pain?
History of onset, duration, character, frequency, radiation, association with exertion, assessment of associated symptoms (fever, syncope, dyspnea, sweating), past medical history, and family history can help differentiate various etiologies of chest pain. Physical examination includes cardiac, respiratory, and abdominal exam especially assessing for hypoxia, tachypnea, tachycardia, fever, cardiac murmurs, gallop rhythm, and rubs point toward need for urgent diagnostic workup. Fig. 18.2 shows an algorithmic approach in assessment of a pediatric patient with chest pain.
(From Friedman KG, Alexander ME: Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. J Pediatr 163(3):896-901, e1-e3, 2013 [Fig. 2, p 10].)
Note: As mentioned in the algorithm, symptoms suggestive of unstable vital signs or cardiac exam concerning for failure should be urgently referred to an emergency department.
5
What are important past medical and family history in patients with chest pain?
Past medical history includes congenital heart disease, cystic fibrosis, Kawasaki disease, Marfan syndrome, Turner syndrome, Noonan syndrome, Ehlers-Danlos syndrome, ankylosing spondylitis, systemic lupus erythematosus, sickle cell disease, asthma, anxiety, and panic attacks. Family history of prolonged QT syndrome, sudden cardiac deaths, and cardiomyopathies point toward concerning pathology in patients.
7
What are the characteristic historical or physical findings in patients with chest wall pain?
Costochondritis pain is usually worse with breathing or exercise, mostly unilateral, anterior, reproducible at the costochondral areas, involving two or more costochondral joints, and may be persistent for weeks. If there is localized inflammation, pain, swelling, and erythema of one costochondral joint (usually second/third joint), the condition is called Tietze syndrome. Paroxysms of sharp chest pain associated with coxsackievirus infection is called pleurodynia (Bornholm disease).
8
What are the other causes of benign chest pain?
Precordial catch (Texidor twinge) is usually left sided, recurrent, lasting for a few seconds, with a point location in an intercostal space, worsening on deep breathing or bending down, and improving with shallow breathing. Unilateral burning or sharp pain in a dermatomal distribution is typical of herpes zoster. Various breast conditions can also present with chest pain. Esophageal spasm can lead to severe retrosternal chest pain while gastroesophageal reflux can lead to burning pain after meals or worsening with laying down. Noncardiac chest pain can be due to psychosocial stressors or conditions like depression, anxiety, stress, conversion, or somatization. It is usually reported as frequent, recurrent, severe, lasting for varied duration, spanning over months to years, with no consistent relationship with activity, usually without any other associated symptoms, with or without hyperventilation or obvious anxiety, affecting daily life routine.
9
Which medical conditions can present with sudden chest pain?
There are six serious conditions for an urgent care physician to consider with acute onset of atraumatic chest pain: acute asthma, spontaneous pneumothorax or pneumomediastinum, acute chest syndrome in patients with sickle cell disease, and, uncommonly, pulmonary embolism or aortic dissection. Sudden onset of chest pain in an otherwise healthy young child may be due to foreign body ingestion. Sudden increase in intrathoracic pressure associated with trauma, asthma, pneumonia, vomiting, weight lifting, inhalation of recreational drugs, or hookah may lead to pneumomediastinum or pneumothorax ( Fig. 18.3 ). Pain is unilateral with shortness of breath with pneumothorax. Pneumomediastinum pain is located in the neck and retrosternal area with subcutaneous emphysema and Hamman sign (crunchy sound over precordium). If it is associated with profound vomiting, then esophageal perforation needs to be ruled out. Fever, cough, respiratory distress, and chest pain are presenting signs of acute chest crisis in patients with sickle cell disease. Cocaine abuse can present with angina with chest tightness, nausea, sweating, vomiting, or shortness of breath. Aortic dissection is rarely seen in pediatric patients and is associated with collagen vascular disorders.
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