Evaluation of Chest Pain

in the Pediatric Patient

Jennifer Thull-Freedman, MD, MSCI, FAAP(PEM)
Assistant Professor of Paediatrics
University of Toronto
Co-director, PEM Clinical Fellowship
The Hospital for Sick Children

From my residency

A 12-year-old previously healthy boy presented

to the ED after first seeking care at the
neighborhood fire department for chest pain

Told to take a warm bath for muscle aches

Arrived several hours later alert but in pain

HR=130, BP not done
CXR obtained
Child waited in room for CXR to be reviewed

From my residency

Child suddenly became unresponsive and

pulseless
Unable to be resuscitated
CXR reviewed during resuscitation showed
widened mediastinum
Autopsy revealed dissection of the aorta

However

Most cases of chest pain in children are not

related to serious pathology
History and physical exam often sufficient
evaluation

The challenge

Objectives

Review relevant literature

Review common causes of chest pain in children
Discuss uncommon but serious causes
Present an approach to the child with chest pain
Summarize take-home points

Etiology of chest pain in kids

Very few studies

Most retrospective
Variable inclusion/exclusion criteria
Limited detail provided

Selbst et al.

Objectives:
Identify causes of chest pain in children
Assess value of echocardiogram

Prospective
Enrolled all patients with chest pain
ECG and echo offered to those with ill-defined
or suspected cardiac etiology
Pediatrics 1988; 82: 319-323

Selbst et al.

Population
407 patients
Philadelphia, Pennsylvania
Median age 12.5 years
55% female, 90% African-American
43% acute pain <48 hours
Did not exclude known disease

Pediatrics 1988; 82: 319-323

Selbst et al.

ECGs in 191/235 children

31 abnormal (16%)
27

minor or previously known findings

3 dysrhythmias detected on physical exam
1 with known SLE had findings of pericarditis

Pediatrics 1988; 82: 319-323

Selbst et al.

Echocardiograms in 139/235

17 abnormal (12%)
12

mitral valve prolapse (8.6%)

Similar prevalence to general population
2 pericardial effusion
2 mitral valve regurgitation
1 poor LV function

Pediatrics 1988; 82: 319-323

Selbst et al.

Chest radiographs in 137/407

37 abnormal (27%)
Most

frequent: infiltrates, atelectasis, hyperinflation

1 pneumothorax in a child with Marfans syndrome
1 clavicle fracture suspected clinically
1 child with SLE had pleural effusion, large heart

Pediatrics 1988; 82: 319-323

Selbst et al.

Diagnostic categories
25
20
15
10
5
0

Idiopathic

Resp.

Chest Wall

Psych.

Trauma

Cardiac

GI

Other

Selbst et al.

Organic disease related to

Age <12 years
Pain awakening child from sleep
Acute onset
Abnormal physical exam
Not related to description or location of pain

Pediatrics 1988; 82: 319-323

Selbst et al. #2

6-month follow-up of 149/407 patients

43% had intermittent or persistent pain
No significant disease identified

mitral valve prolapse

1 gastrointestinal disease
3 asthma

Conclusion:

H&P sufficient for identifying majority of significant

etiologies
Clinical Peds 1990; 29: 374-7

Rowe et al.

325 CHEO PED patients

Primary or secondary complaint of chest pain
30
25
20
15
10
5
0

Chest Wall

Resp.

Psych.

Trauma

GI

Cardiac

Other

CMAJ 1990; 143:388-94

Rowe et al.

Chest X-rays done in 50%

18/161 with positive result

15 infiltrates
2 pneumomediastinum
1 pneumothorax

ECG done in 18%

2/60 with significant new findings

Tachycardia and ST changes suggested myocarditis
WPW

CMAJ 1990; 143:388-94

Massin et al.

168 patients in Belgian PED with chest pain

69 patients in cardiology clinic with chest pain

90

PED
Card Clinic

80
70
60
50
40
30
20
10
0

Chest Wall

Resp.

Psych.

Cardiac

Trauma

GI

Other

Clin Pediatr 2004;43:231-8

Massin et al.

9 cases cardiac etiology in 168 PED patients

3 SVT
2 MVP
4 sick sinus
1 myocarditis
1 pericarditis
1 cardiac hemochromatosis with -thalassemia

5 cases cardiac etiology in 69 card. clinic patients

5 SVT

Clin Pediatr 2004;43:231-8

Massin et al.

Results

Palpitations or abnormal auscultation predicted all

cases of cardiac disease

Conclusions
Chest pain in children usually benign
History and physical usually sufficient
Laboratory testing guided by H&P

Clin Pediatr 2004;43:231-8

Limitations of current literature

Small numbers for characterizing rare events

Limited detail
Children with known disease not excluded
Lack of follow-up
No evidence-based guidelines

Differential Diagnosis

Chest wall

Trauma
Costochondritis
Precordial catch
Slipping rib
Infection
Mastalgia
Zoster

Gastroesophageal

Reflux
Foreign body

Pulmonary

Hematologic

Asthma
Pneumonia/effusion
Pneumothorax
Pleurisy
Pulmonary embolus
Malignancy
Sickle cell disease

Psychogenic

Differential Diagnosis

Cardiac

Angina
Coronary abnormalities
Hypercoagulable state
Cocaine
Obstructive heart disease
IHSS, aortic stenosis
Pericardial effusion/pericarditis
Arrhythmias
Myocarditis
Aortic aneurysm

Cases

Case

A 12-year-old girl presents to the emergency

department with chest pain for 2 days
Started gradually
Worse with deep breath
Had URTI last week
Afebrile
Tender on both sides of sternum
Remainder of physical exam normal

Costochondritis

Inflammation of costochondral cartilage

Cause
Overuse
Preceding URTI with cough
Idiopathic

Sharp pain, worse with movement

All ages
Tenderness over costochondral joints

Guess the eponym

Costochondritis
+ visible costochondral swelling
=

Case
A 10-year-old boy presents to the ED with
recurrent episodes of left chest pain.
Feels like a sudden stab
Cant take a deep breath
Lasts 2-3 minutes
Occurs at rest
Not reproducible
Normal physical exam

Guess the eponym

Precordial Catch Syndrome

Texidors twinge
Sudden, brief
Occurs at rest
Localized
Sharp
Exacerbated by deep breath
No associated symptoms
No physical findings

Case

A 6-year-old girl comes to the emergency

department after having chest pain at home.
Stopped playing, became clingy, said chest hurt
Mom thought she looked pale
Now looks and feels better
HR=110, normal physical exam

SVT

In children >1 year

82% present with palpitations
14% with pain
14% perspiration
14% dizzy
4% pallor

1-3% of chest pain complaints in ED

6% of chest pain referred to cardiologist
Median time from symptoms to diagnosis 138d

Case

A 13-year-old boy presents to the emergency

department with sudden severe chest pain
Sharp pain in anterior chest
Appears anxious
BP 80/40 in right arm
Diastolic murmur

Marfan syndrome

Caused by fibrillin gene mutation

Manifestations
Musculoskeletal: Tall, long limbs and fingers, pectus
Ocular: Lens dislocation
Cardiovascular: Aortic root dilation, MVP
Pulmonary: Spontaneous pneumothorax

50% have aortic root dilation by age 10 years

90% have aortic root dilation by age 20 years

Aortic dissection

Children at risk
Marfan syndrome
Ehlers-Danlos
Coarctation
Aortic stenosis
Turner syndrome
Endocarditis
Cocaine use

Case

A 17-year-old female presents to the ED with

chest pain that has lasted for 1 hour
Pain began during soccer practice
Has happened previously with exercise
Midsternal, squeezing, radiates to left arm
PMH: Admitted to hospital for FUO at age 2 years

What was the FUO?

Kawasaki Disease

Acute febrile vasculitis of childhood

Features
Fever (>39 degrees for 5 days)
Non-exudative conjunctivitis
Erythema of oral mucosa and tongue
Erythema and swelling of hands and feet
Cervical adenitis >1.5 cm
Rash

Leading cause of acquired heart disease in kids

Cardiac sequelae of KD

Acute and subacute

Myocarditis (50% of patients)
Pericarditis
Mitral, aortic insufficiency
Arrhythmias
Coronary aneurysms

20-25%

if untreated
5% if treated with IVIG
Appear 7 days to 4 weeks after onset of fever

Cardiac sequelae of KD

Long-term follow-up (> 10 years) of 594

untreated patients
IVIG treatment standard since late 1980s
24.6% had coronary aneurysms

49%

had regression
19% developed stenosis (4% of total)
8% developed myocardial infarction (2% of total)

Circulation 1996;94:1379-85

Myocardial ischemia in kids

Anomalous coronary arteries

Prevalence 2:1000
Anomalous origin of L coronary from pulm. artery

Presents

in first months of life

Irritability, heart failure, cardiac enlargement

Anomalous origin from incorrect sinus of Valsalva

Presents

later in childhood
Compression between aorta and pulm. artery

Hypoplastic coronary arteries

Myocardial ischemia in kids

Sickle cell disease

Myocardial infarction uncommon but described
Perfusion defects in 5% children studied in a Paris
sickle cell clinic (Arch Dis Child 2004;89:359-62)
Microvascular occlusion of small vessels
Exchange transfusion may be helpful for acute
ischemia (Pediatrics 2003;111:e183-7)

Myocardial ischemia in kids

Nephrotic syndrome

Thrombotic occlusion of coronary arteries

Long-standing diabetes mellitus

Familial hypercholesterolemia
SLE, Antiphospholipid antibody syndromes
Cardiac transplant
Cocaine abuse

Case

A 16-year-old boy presents to the emergency

department after fainting at a track meet
Remembers having chest pain during his race
Father died suddenly in his 30s
Systolic murmur on exam

Hypertrophic cardiomyopathy

Autosomal dominant
Symptoms in 2nd decade
May present with angina-like pain or syncope

Impaired diastolic relaxation, increased O2 demand

Risk of sudden death 6% in children

Hypertrophic cardiomyopathy

Diagnosis

Systolic ejection murmur

Increases

with decreased LV volume

(Valsalva, squatting, standing)

Normal or increased heart size on CXR

ECG with LVH, LAD, conduction abnormalities
Echocardiography diagnostic

Case

A 6-year-old girl presents to the ED with cough

for 3 weeks and chest pain for 1 week
Feels very tired
Illness began with URTI 3 weeks ago
Afebrile
Heart rate = 160
Liver palpable 3 cm below RCM

Myocarditis

Usually viral etiology

Enterovirus (coxsackie), adenovirus

Presentation
Heart failure
Chest pain

More

likely in older kids and adults

Ischemia or concurrent pericarditis

Myocarditis

Physical findings
Tachycardia, tachypnea
Poor perfusion
Muffled heart sounds, S3, murmur
Hepatomegaly

CXR
Cardiomegaly
Pulmonary edema

Myocarditis

ECG
Sinus tachycardia
Decreased voltages (<5 mm) limb leads
LVH
Prolonged PR interval, prolonged QT interval

Echocardiogram

Hypokinesis, impaired function

Case

You are working in the ED when a nurse

asks you to assess a 15-year-old girl with
chest pain who seems unwell. You recall
treating her for pneumonia last week.
Worsening dyspnea and chest pain for 3 days
Leaning forward holding her chest

Pericarditis

Infectious etiology common in children

Pain
More common in older children and adolescents
Worse when supine, relieved by leaning forward

Physical findings
Friction rub if effusion small
Muffled heart sounds, pulsus paradoxus if large

Pericarditis

ECG
Low voltages
ST elevation

Usually

leads I, II, V5, V6

Electric alternans
Produced

effusion

by swinging motion of heart within

Case

A 9-year-old obese boy is brought to the ED at

11pm complaining of chest pain since dinner
preventing him from sleeping
Has been having episodes for few weeks
Described as burning
Worse after big meals and when lying down
Normal physical exam

Gastroesophageal Reflux

Berezin et al.
27 children 8-20 years with idiopathic chest pain
All received EGD, manometry, pH monitoring
Not blinded, no control group
Results: 78% had gastroesophageal cause

16

of 27 (59%) had esophagitis

4 of 27 (15%) had gastritis
1 of 27 (4%) with abnormal manometry
Archives Dis Child 1988;63:1457-60

Gastroesophageal Reflux

Accounts for 5-10% of PED chest pain visits

Classic pain is temporally associated with meals
Burning, retrosternal
Trial of antacid, H2RA, PPI is appropriate
Consider pH probe if diagnostic testing needed

Case

A 3-year-old boy is evaluated in the emergency

department with chest pain for several hours
Points to sternal notch
Drooling
Refusing juice
Afebrile, well-appearing
Breath sounds equal

Esophageal foreign body

Case

An 8-year-old boy is brought to the ED directly

from a hockey practice during which he said his
chest hurt and he couldnt breathe
Several similar episodes
Feeling better since arrival to ED
Tight cough
Normal breath sounds, no murmur
Normal CXR and EKG

Asthma

May account for 10-20% chest pain in kids

Personal or family history atopic conditions
Associated with cough
May be worse at night or with exercise
Wheezing not always detectable
Trial of bronchodilator
Consider PFT for pain with exercise

Case

A 17-year-old boy presents to the emergency

department with right chest pain
Just returned hours ago from vacation in Cozumel
Pain began one day ago
Progressive dyspnea during flight home

Pneumothorax/pneumomediastinum

Children at risk
Asthma, bronchiolitis
Barotrauma
Cough, choking, vomiting
Crack, cannabis
Cystic fibrosis
Marfan syndrome
Tall male teenagers

Case

A 15-year-old girl presents to the ED with chest

pain
Present for several days
Reports feeling dizzy and short of breath
Not associated with exercise
Physical exam unremarkable
Grandmother died last week of heart attack

Psychogenic

5-20% of chest pain in children

More common in adolescents
Recent or current stressful situation
Family illness, especially cardiovascular
Family history of chest pain
Other somatic and sleep complaints
Depression

The approach: History

Description of pain

Not as reliable in children as in adults

Precipitating factors
Exertion
Eating
Deep breathing
Muscle use
Trauma
Emotional stress

The approach: History

Frequency and chronicity

Associated symptoms
Fever
Cough
Shortness of breath
Syncope
Dizziness
Palpitations

The approach: History

Past medical history

Known heart disease
Asthma or atopic conditions
Prothrombotic conditions

Cancer
SLE
Nephrotic

syndrome

Medications and drugs

Family history

The approach: Physical exam

General appearance
Body habitus
Vital signs
Chest wall palpation
Auscultation
Abdomen
Peripheral perfusion

Red flags

Pain associated with exercise, palpitations, or syncope

Shortness of breath
Pain limits daily activities or disturbs sleep
Substance abuse
Presence of prothrombotic conditions
PMH consistent with Kawasaki disease
Family history of sudden death or
early cardiac death
Abnormal vital signs or physical findings

The approach

Further evaluation
CXR
ECG
Holter monitor
Echocardiogram
Cardiology consultation
Therapeutic trials

Summary

Chest pain in pediatrics usually due to benign,

identifiable etiology
Cardiac and other life-threatening causes of
chest pain rare but do exist
Often can be ruled out by history and physical exam
Diagnostic tests appropriate in presence of red flags

The End