Respiratory

Chest Pain

Chest pain is a common pediatric complaint with the average presenting age of 12. The younger the patient, the more likely an organic etiology will be found although there is rarely a serious underlying disease. In fact, more than 45% of pediatric chest pain cases elude definitive diagnosis. A thorough history and physical examination will help differentiate a serious cause from a minor problem.

 

Differential Diagnosis of Chest Pain

  1. Cardiac. Chest pain of cardiac origin is suggested by pain that increases with physical exertion, history of palpitations, and an ill appearance. A family history of cardiac disease or sudden unexplained death are significant. Physical findings of arrythmias, murmurs, muffled heart tones and blood pressure changes warrant further evaluation.
    1. Anomalous coronary arteries
    2. Kawasaki's Disease
    3. Myocardial dysfunction in myocardopathies and myocarditis
    4. arrythmias
    5. Hypertrophic obstructive myocardopathy
    6. Mitral valve prolapse
    7. Pericarditis
    8. Familial hypercoholesteremia
    9. Aortic dissection (Risk factors include HTN, Marfan’s, Ehler’s-Danlos, cocaine use, congenital bicuspid aortic valve)
    10. Precordial Catch Syndrome – a diagnosis of exclusion
  2. Musculoskeletal Pain. Pain secondary to musculoskeletal causes are usually diagnosed by history and physical exam. The pain is usually worse with movement of the chest and tenderness may be elicited. May be frank evidence of trauma with swelling and bruising.
    1. Muscle strains secondary to exercise and sports
    2. Trauma
    3. Rib injuries
    4. Costochondritis- tenderness at the junction, Osteomyelitis of the rib
    5. Teitze syndrome – similar pain to costochondritis, but with swelling of the sternochondral junctions
  3. Pulmonary. History and physical examination should lead to the diagnosis of chest pain secondary to pulmonary causes.
    1. Coughing secondary to asthma, pneumonia, or URI may lead to muscle strain and pain
    2. Exercise induced asthma
    3. Pneumothorax and pneumomediastinum
    4. Pulmonary embolism
    5. Pleural effusion
    6. Pleuritis (Risk factors include connective tissue disease)
    7. Pleurodynia
  4. Psychogenic. Often this diagnosis is made after a careful history elicits the cause of stress and anxiety leading to somatization. School changes, family problems, depression, changes in friends may be clues to the origin of the chest pain.
  5. Gastrointestinal disease
    1. Gastroesophogeal reflux
    2. Foreign body in the esophagus
    3. Peptic ulcer disease
    4. Gall bladder disease
    5. Mallory Weiss tear/Boerhaave’s syndrome (very rare)
  6. Hematologic/Oncologic
    1. Sickle cell disease – vasoocclusive crises, acute chest syndrome
    2. Anterior mediastinum tumor: lymphoma, thymoma
    3. Posterior mediastinum tumor: neuroblastoma, neurofibroma, sarcoma, teratoma
  7. Miscellaneous
    1. Breast changes 
    2. Spinal cord abscess
    3. Cocaine and/or methamphetamine abuse

 

Evaluation of Patient with Chest Pain

In most cases, a thorough history and physical examination will eliminate an organic cause for the chest pain in the pediatric patient. Significant history

  1. Sudden onset of pain and pain that wakes the child from sleep
  2. Family history of cardiac disease and anomalies 
  3. Associated with exercise, fainting, palpitations, and shortness of breath.
  4. Poor growth
  5. Chronic pain without limitation of activities 
  6. Family member or friend with recent onset of chest pain

 

Physical Findings

  1. Evidence of trauma
  2. Evidence of distress
  3. Murmurs or irregular heart rate
  4. Signs of shortness of breath, respiratory distress, wheezing, rales, decreased breath sounds. 

In the majority of cases, if the history and physical exam are normal, no laboratory evaluation will be necessary. If there is suspicion of lung or heart disease, a cardiogram and chest radiograph should be performed. The parents and patient must be reassured and told of significant symptoms and changes that they must notify you about. It is imperative to explain that the patient is experiencing the pain but that you can not find an organic etiology. If you suspect a pyschogenic cause, unnecessary referrals and laboratory investigations may make it more difficult to convince the family later that there is no organic basis for the pain. Regular activities should be encouraged for the child. In general, if the child's daily life is severely affected by the chest pain, further evaluations should be considered.

 

References

  1. Selbst S.M. Consultation with the Specialist: Chest Pain in Children. Pediatrics in Review 1997
  2. Kocis K.C. Chest Pain in Pediatrics. Pediatric Clinics of North America 1999
  3. Galioto F. Chest Pain; Course of Action.  Contemporary Pediatrics May 2007
  4. Reddy S.R.V. and Singh H.R. Chest Pain in Children and Adolescents. Peds in Review 2010
  5. Cico S.J. et al. Miscellaneous causes of pediatric chest pain. Pediatr. Clin North Am 2010
  6. Eslick G.D. Epidemiology and risk factors for pediatric chest pain: a systematic review. Pedatr.Clin North Am. 2010
  7. Saleeb S. et al. Effectiveness of screening for Life-Threatening Chest Pain in Children.  Pediatrics Nov 2011
  8. Friedman K.G. et al. Management of Pediatric Chest Pain Using a Standardized Assessment and Management Plan. Pediatrics 2011