Chest pain (peds)

This page is for pediatric patients. For adult patients, see: chest pain

Background

• Common cause of presentation to the ED, especially in adolescents
• The vast majority (>95%) of pediatric chest pain is benign and non-cardiac in origin
• Most common causes are musculoskeletal (costochondritis, muscle strain), idiopathic, and respiratory
• Cardiac causes are rare but must be identified: pericarditis, myocarditis, arrhythmias, coronary anomalies
• Family history plays an important part screening for familial history of sudden death, hypertrophic cardiomyopathy, long QT syndrome, or Marfan syndrome

Red Flags for Cardiac Etiology

• Exertional chest pain or syncope
• Associated palpitations, syncope, or near-syncope
• History of Kawasaki disease (coronary aneurysms)
• Known congenital heart disease or cardiac surgery
• Family history of sudden cardiac death at age <50, HCM, LQTS
• Pain associated with fever (consider pericarditis, myocarditis)
• New murmur or abnormal cardiac exam
• Marfan syndrome habitus (consider aortic root dissection)

Clinical Features

History

• Onset, location, duration, character, radiation, exertional vs. rest
• Reproducibility with palpation (suggests musculoskeletal)
• Associated symptoms: fever, dyspnea, palpitations, syncope, cough, anxiety
• Recent illness, trauma, or strenuous activity
• Drug/substance use in adolescents (energy drinks, stimulants, vaping)

Physical Exam

• Vital signs including pulse oximetry
• Chest wall palpation for tenderness (reproducible tenderness suggests musculoskeletal cause)
• Cardiac auscultation: murmurs, rubs, gallops, muffled heart sounds
• Lung auscultation: wheezing, crackles, decreased breath sounds
• Assess for Marfan syndrome features: tall stature, arm span > height, arachnodactyly, pectus deformity

Differential Diagnosis

Chest pain (peds)

• Idiopathic (most common)
• Precordial catch syndrome
  • Sudden, intense pain with deep inspiration, self-resolving
  • Usually located to one finger point and the intercostal space (often at apex of heart)
• Musculoskeletal
  • Costochondritis, trauma
• Pulmonary
  • Pneumothorax
  • Pneumonia (peds)
  • Pulmonary embolism
  • Aortic dissection
    • Uncommon but consider with history of connective tissue disease
• GI
  • Esophagitis
  • Esophageal spasm
  • Gastritis
• Psychosomatic
  • Panic attack
  • Anxiety
• Cardiac (1%)
  • Left-sided obstructive lesions
  • Dysrhythmias
  • HOCM
  • Pericarditis
  • Prinzmetal's angina (vasospasm)
  • MI
    • Rare, even post-Kawasaki
    • Consider coronary artery dissection
  • Mitral valve prolapse
  • Anomalous coronary arteries]

Evaluation

Low Risk (Typical Musculoskeletal)

• Reproducible chest wall tenderness, no red flags
• No further workup generally needed
• Consider CXR if history of cough, fever, or dyspnea

Moderate to High Risk

• ECG: evaluate for ST changes, arrhythmia, prolonged QTc, ventricular hypertrophy, Brugada pattern
• CXR: cardiomegaly, pneumothorax, pneumonia, mediastinal widening
• Troponin if concern for myocarditis or pericarditis with myocardial involvement
• BNP or NT-proBNP if concern for heart failure
• Consider echocardiography for: new murmur, abnormal ECG, suspected pericardial effusion, known cardiac disease
• Consider CT angiography for suspected pulmonary embolism (rare in pediatrics, but consider in adolescents with risk factors)

Management

Musculoskeletal (Most Common)

• Reassurance — this is the most important intervention
• NSAIDs (ibuprofen) for pain control
• Activity modification as needed

Cardiac Causes

• Pericarditis: NSAIDs + colchicine, cardiology consultation
• Myocarditis: admit, cardiology, hemodynamic monitoring, avoid NSAIDs
• Arrhythmia: see SVT (peds), ventricular tachycardia
• Pneumothorax: see Pneumothorax management
• Aortic pathology: emergent surgical consultation

Disposition

Admit

• Hemodynamically unstable
• Suspected myocarditis or large pericardial effusion
• Significant arrhythmia
• Pneumothorax requiring intervention

Discharge

• Musculoskeletal chest pain with normal exam and no red flags
• Stable patients with mild pericarditis (arrange cardiology follow-up)
• Provide clear return precautions: worsening pain, exertional symptoms, syncope, palpitations, fever
• Cardiology referral for: abnormal ECG, family history of sudden death, exertional symptoms

See Also

• Chest pain
• Acute chest pain
• Pericarditis
• Myocarditis
• Kawasaki disease