Chest pain in children

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:

Synonyms and Keywords: Chest pain in kids

Overview

Historical Perspective

Chest pain in children is a common symptom and has a broad etiology. usually, history and physical examination can determine the cause and help in the differentiation of patients who require further investigations.

Classification

Chest pain in children can be classified to:

  • Cardiac
  • Non-cardiac

Pathophysiology

    • The pathogenesis of chest pain differs according to the cause may be:
    • Inflammatory process in myocarditis, pericarditis, Kawasaki disease, Asthma, pneumonia, esophagitis, and costochondritis.
    • Hypertrophy in hypertrophic cardiomyopathy.

Causes

Common causes of Chest pain in children include:

Non Cardiac Causes:

Idiopathic

Musculoskeletal

  1. Muscle strain
  2. Trauma
  3. Costochondritis
  4. Precordial catch syndrome

Respiratory

  1. Asthma
  2. Pneumonia
  3. Pneumothorax
  4. Pulmonary embolism
  5. Inhaled foreign body.
  6. Chronic cough

Gastrointestinal

  1. Gastroesophageal reflux( GERD)
  2. Esophagitis
  3. Gastritis
  4. Foreign body

Miscellaneous

  1. Psychogenic and Anxiety
  2. Sickle cell disease
  3. Herpes zoster

Cardiac Causes:

  • Anomalous coronary arteries
  • Kawasaki disease
  • Dysrhythmias
  • Pericarditis
  • Myocarditis
  • Hypertrophic cardiomyopathy
  • Mitral valve prolapse
  • Aortic stenosis
  • Aortic aneurysm

Epidemiology and Demographics

  • Patients with chest pain account for 650,000 visits annually in patients age group from10 to 21 years.
  • Patients with chest pain account for 5.2% of all cardiology consultations in the inpatient and emergency departments. and 15% of all outpatient visits.
  • Studies estimated only 0% to 5% of patients with chest pain have a cardiac etiology.

Natural History, Complications and Prognosis

  • The majority of patients with chest pain have bengin non cardiac causes.
  • Prognosis is generally good in non-cardiac causes.

Diagnosis

Symptoms

Symptoms of chest pain may include the following:

  • Chest wall pain
  • Dyspnea
  • Cough
  • Heartburn
  • Pain after taking medications
  • Fever

Physical Examination

  • Physical examination may reveal:
  • Chest wall tenderness in muscle strain and costochondritis
  • Murmur, gallop, pericardial friction rub, distant heart sounds, and abnormal second heart sound (loud S2)
  • Irregular rhythm,
  • Peripheral edema
  • Cyanosis
  • Tachypnea
  • Skin rash

Laboratory Findings

  • Cardiac troponin
  • CBC
  • CRP
  • ESR

Electrocardiogram

An ECG should be obtained if a cardiac disease is suspected and when a noncardiac etiology is not clear.

ECG abnormalities can help with diagnosis:

  • Dysrhythmia. However, in intermittent events, the initial ECG will be normal.
  • Hypertrophic cardiomyopathy: left ventricular hypertrophy or strain.
  • Pericarditis: generalized ST-segment elevation followed by T wave inversion.
  • Myocarditis: ST-T wave abnormalities.
  • Anomalous origin of the left coronary artery from the pulmonary artery: anterolateral infarction with deep and wide Q waves and T wave inversions in leads I, aVL, V5, and V6.
  • Pulmonary hypertension: signs of right ventricular hypertrophy and right axis deviation.
  • Pulmonary embolism: nonspecific ST-T segment changes or sinus tachycardia.

X-ray

An x-ray may be helpful in the diagnosis of the cause of chest pain.

The x-ray may show:

  • Cardiac enlargement in myocarditis and pericardial effusion
  • Prominent main and central pulmonary arteries. in pulmonary hypertension
  • infiltrates in pneumonia
  • atelectasis
  • Hyperinflation in asthma.
  • Pneumothorax, pneumomediastinum, or pleural effusions.
  • Radio-opaque esophageal foreign body (eg, button battery, or coin).

Echocardiography or Ultrasound

-Echocardiography may show many incidental findings but also it can help in the diagnose of serious causes of chest pain, including hypertrophic cardiomyopathy, anomalous coronary artery origin, pericardial effusion, and pulmonary hypertension.

-Echocardiography is indicated in the patients with the following:

  • Exertional chest pain or syncope.
  • Chest pain associated with fever.
  • History of congenital heart disease, Kawasaki syndrome, or diseases that raise cardiac risk (eg, malignancy, hypercoagulable state).
  • Family history of cardiomyopathy, sudden death.
  • New murmur
  • Distant heart sounds
  • Pericardial friction rub
  • Loud S2
  • Peripheral edema
  • Abnormal electrocardiogram.

CT scan

CT scan may be helpful in the diagnosis of the cause of chest pain, including pulmonary embolism, aortic aneurysm and dissection, and tumors.

MRI

MRI scan may be helpful in the diagnosis of the cause of chest pain, including myocarditis, Arrhythmogenic right ventricular dysplasia (ARVD), and tumors.

Other Diagnostic Studies

Holter monitoring to diagnose arrhythmia as a cause of intermittent chest pain.

Treatment

Medical Therapy

The management depends on the clinical status and stability of the patient, patients with severe respiratory distress, hemodynamic instability require rapid care of the (ABC) airway, breathing, and circulation according to the Pediatric Advanced Life Support (PALS).

The medical management of stable patients differs according to the cause:

  • Costochondritis and ms strain can be treated with NSAIDs and muscle relaxants.
  • Infections like pneumonia can be treated with antibiotics, supplemental oxygen, and mechanical ventilation as needed
  • Gastritis and esophagitis can be treated with H2 blockers and PPIs.
  • Acute chest syndrome in sickle cell disease managed with pain control, antibiotics, hydration and blood transfusion, or exchange transfusion.
  • Pulmonary embolism requires anticoagulant therapy or, thrombolytics in hemodynamically unstable children.
  • Ischemia and myocardial infarction should receive anticoagulation, pain management, and catheterization.
  • Heart failure should be managed with diuretics, ACEIs, and beta-blocker if no contrindication.
  • Tachyarrhythmias should be managed according to Pediatric Advanced Life Support (PALS).
  • Pericarditis with pericardial effusion requires pericardiocentesis in patients with tamponade.
  • Tumors require further workup and the management differs according to the type of the tumor.

Surgery

  • Aortic root dissection managed with requires emergent surgical intervention.
  • Tension pneumothorax requires a needle or chest tube thoracostomy.
  • Airway foreign body with obstruction requires emergent securing of the airway and bronchoscopy.
  • Esophageal foreign body: management depends on the type of body. sharp foreign bodies, impacted batteries, or magnets require urgent removal.

References

  1. Yeh TK, Yeh J.Chest Pain in Pediatrics. Pediatr Ann. 2015; 44:274.
  2. Ji Hye Chun, et al.Analysis of clinical characteristics and causes of chest pain in children and adolescents. Korean J Pediatr. 2015; 58: 440.
  3. Friedman KG, Alexander ME. Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. J Pediatr. 2013; 163:896.
  4. Selbst SM. Approach to the child with chest pain. Pediatr Clin North Am. 2010; 57:1221