Evaluation of Chest Pain in Children

Etiology and Clinical Evaluation

• Pneumonia may present with localized pleuritic pain and friction rub, according to the American College of Cardiology 1
• Costochondritis, a musculoskeletal cause, is often characterized by tenderness of costochondral joints, as noted by the American College of Cardiology 2
• Herpes zoster can cause pain in a dermatomal distribution, as reported by the American College of Cardiology 2
• Pain characteristics, such as onset, duration, location, quality, and radiation, are important to assess, as recommended by the American Heart Association 3 and the American College of Cardiology 4
• Pleuritic pain, which is sharp and worsens with breathing, suggests a respiratory etiology, according to the American College of Cardiology 1
• Fever may suggest infection, as noted by the American College of Cardiology 2
• Dyspnea and cough may suggest a respiratory cause, as reported by the American College of Cardiology 2 and the American College of Cardiology 1
• Vital signs, including temperature, heart rate, respiratory rate, and blood pressure, should be assessed, as recommended by the American College of Cardiology 2
• The respiratory system should be evaluated for abnormal breath sounds, decreased breath sounds, and friction rub, as noted by the American College of Cardiology 2 and the American College of Cardiology 1
• The cardiovascular system should be assessed for murmurs, abnormal heart sounds, and irregular rhythm, as recommended by the American College of Cardiology 2
• The musculoskeletal system should be evaluated for chest wall tenderness and reproducible pain with palpation, as noted by the American College of Cardiology 1

Diagnostic Approach

• A focused history and physical examination should guide the need for further testing, as recommended by the American Heart Association 5 and the American College of Cardiology 2
• Severe respiratory distress, signs of cardiac compromise, and sudden onset of severe pain with systemic symptoms require immediate attention, as noted by the American Heart Association 5

Management and Follow-Up

• Appropriate antibiotics should be used to treat pneumonia, as recommended by the American College of Cardiology 2
• Children should be followed until symptoms have resolved, as noted by the Thorax journal 6
• Underlying diagnoses, such as immunodeficiency or congenital anomalies, should be considered in cases of recurrent or persistent symptoms, as reported by the Thorax journal 6

Evaluation of Sternal Chest Pain in Children

Initial Assessment and History

• The American College of Cardiology suggests that pain characteristics, such as exact location on the sternum, quality, onset, duration, and severity, should be obtained in the history of children presenting with sternal chest pain 7
• The American College of Cardiology recommends assessing the radiation pattern of the pain, including to arms, jaw, neck, or back, in children with sternal chest pain 7
• The American College of Cardiology advises evaluating precipitating factors, such as exertion, stress, breathing, position changes, or meals, in the history of children with sternal chest pain 7
• The American College of Cardiology suggests assessing associated symptoms, including fever, dyspnea, cough, diaphoresis, nausea, syncope, or palpitations, in children with sternal chest pain 7
• The American College of Cardiology recommends considering the temporal features of the pain, including fleeting pain lasting only seconds, which is unlikely to be cardiac in nature 7

Diagnostic Testing and Management

• The American Academy of Pediatrics suggests that a chest radiograph may be indicated if respiratory symptoms, such as cough, dyspnea, or fever, suggest pneumonia or pneumothorax in children with sternal chest pain 8
• The American Academy of Pediatrics recommends considering cardiac troponin testing only if acute coronary syndrome is suspected, which is extremely rare in children 8
• The American Academy of Pediatrics suggests that psychologic or anxiety disorders may be a common cause of chest pain in children, with 81% of children with unexplained chest pain meeting criteria for anxiety disorders 9

Management Approach

• The American Academy of Pediatrics recommends providing a thorough explanation to children with benign causes of chest pain, taking their symptoms seriously, and explaining the benign nature of their condition when an organic cause is excluded 9

Evaluation of Pediatric Chest Pain

Initial Assessment and Diagnostic Approach

• The American College of Cardiology suggests that chest pain in children is rarely cardiac in origin, occurring in only 1-5% of cases, and the evaluation should focus on efficiently ruling out life-threatening causes through targeted history, physical examination, and selective testing rather than extensive cardiac workup 10
• Exertional chest pain that occurs during physical activity or emotional stress suggests possible cardiac ischemia, according to the American Heart Association, as reported in Circulation 11
• The American Heart Association, as reported in Circulation, recommends that syncope or presyncope accompanying the chest pain, palpitations, or sensation of irregular heartbeat warrants immediate concern and further cardiac evaluation 11
• Palpitations or sensation of irregular heartbeat is a concern that warrants further evaluation, as suggested by the American College of Cardiology 10
• Sudden onset "ripping" pain radiating to the back suggests aortic dissection, though rare in pediatrics, as indicated by the American Heart Association, as reported in Circulation 11
• Fleeting pain lasting only seconds is unlikely to be cardiac in origin, as suggested by the American Heart Association, as reported in Circulation 11
• Sharp, localized pain that can be pointed to with one finger, positional pain that changes with body position, and reproducible pain with chest wall palpation are reassuring features that suggest a benign etiology, according to the American Heart Association, as reported in Circulation 11

Diagnostic Testing and Management

• The American Heart Association, as reported in Circulation, recommends that an ECG should be obtained within 10 minutes if any concern for cardiac etiology exists, even if musculoskeletal pain is suspected 11
• Cardiac troponin measurement should be done as soon as possible if acute coronary syndrome is genuinely suspected, as indicated by the American Heart Association, as reported in Circulation 11
• Ambulatory ECG monitoring (Holter/event monitor) is recommended for palpitations with suspected arrhythmia, but not indicated for isolated chest pain without palpitations, as suggested by the American College of Cardiology 10
• The American College of Cardiology suggests that exercise stress testing can be eliminated in most cases when using a standardized approach, as it rarely changes management in pediatric chest pain 10
• Consider referral to cognitive-behavioral therapy if cardiac workup is negative and pain persists, as recommended by the American College of Cardiology 12
• Do not assume reproducible chest wall tenderness excludes cardiac disease, and do not use nitroglycerin response as a diagnostic criterion, as indicated by the American Heart Association, as reported in Circulation 11
• Do not delay transfer for troponin testing in office settings, and do not order extensive cardiac testing without clear indications, as suggested by the American Heart Association, as reported in Circulation 11
• Do not dismiss psychogenic causes, provide thorough explanation, take symptoms seriously, and consider referral when organic causes are excluded, as recommended by the American College of Cardiology 12