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{{SI}}                                                                 
{{CMG}} {{AE}}


{{SK}} Chest pain in kids
{| class="infobox" style="float:right;"
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|[[File:Siren.gif|30px|link=Chest pain resident survival guide (pediatrics)]]||<br>||<br>
|[[Chest pain resident survival guide (pediatrics)|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
|} 
{{SI}}                                                               
{{CMG}} {{AE}} {{Mitra}}
 
{{SK}} Chest pain in kids, pediatric chest pain


==Overview==
==Overview==
Chest pain is a common [[symptom]] in children and adolescents. Despite causing considerable concerns and anxiety in [[patients]] and their families, most cases have [[benign]] and non-[[cardiac]] etiologies. A thorough history and [[physical examination]] can reveal [[diagnoses]] in the majority of [[patients]], necessitating laboratory testing and [[imaging]] studies only in a small subset of [[patients]].


==Historical Perspective==
==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.
There is limited evidence on the historical perspective of chest pain in children.  
==Classification==
==Classification==
Chest pain in children can be classified to:
There is no established system for the classification of chest pain in the pediatric population.
 
*Cardiac
*Non-cardiac


==Pathophysiology==
==Pathophysiology==
 
*The pathophysiology of chest pain in children depends on the underlying cause.
**The pathogenesis of chest pain differs according to the cause may be:
**For a complete guide on the pathophysiology of [[asthma]], [[Asthma pathophysiology|click here]].<br />
**Inflammatory process in myocarditis, pericarditis, Kawasaki disease, Asthma, pneumonia, esophagitis, and costochondritis.
**For a complete guide on the pathophysiology of [[gastroesophageal reflux disease]] ([[GERD]]), [[Gastroesophageal reflux disease pathophysiology|click here]].<br />
**Hypertrophy in hypertrophic cardiomyopathy.
**For a complete guide on the pathophysiology of [[pneumothorax]], [[Pneumothorax pathophysiology|click here]].<br />
*
**For a complete guide on the pathophysiology of [[pulmonary embolism]], [[Pulmonary embolism pathophysiology|click here]].<br />


==Causes==
==Causes==
Common causes of Chest pain in children include:
The most common causes of [[chest pain]] in children include musculoskeletal, respiratory, psychogenic, and idiopathic.
A comprehensive list of causes of chest pain in children is presented in the table below:
<ref name="pmid23769502">{{cite journal |vauthors=Friedman KG, Alexander ME |title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease |journal=J Pediatr |volume=163 |issue=3 |pages=896–901.e1–3 |date=September 2013 |pmid=23769502 |pmc=3982288 |doi=10.1016/j.jpeds.2013.05.001 |url=}}</ref><ref name="pmid1697801">{{cite journal |vauthors=Aeschlimann A, Kahn MF |title=Tietze's syndrome: a critical review |journal=Clin Exp Rheumatol |volume=8 |issue=4 |pages=407–12 |date=1990 |pmid=1697801 |doi= |url=}}</ref><ref name="Heinz1977">{{cite journal|last1=Heinz|first1=George J.|title=Slipping Rib Syndrome|journal=JAMA|volume=237|issue=8|year=1977|pages=794|issn=0098-7484|doi=10.1001/jama.1977.03270350054023}}</ref><ref name="pmid4000782">{{cite journal |vauthors=Selbst SM |title=Chest pain in children |journal=Pediatrics |volume=75 |issue=6 |pages=1068–70 |date=June 1985 |pmid=4000782 |doi= |url=}}</ref><ref name="Howell1992">{{cite journal|last1=Howell|first1=John M.|title=Xiphodynia: A report of three cases|journal=The Journal of Emergency Medicine|volume=10|issue=4|year=1992|pages=435–438|issn=07364679|doi=10.1016/0736-4679(92)90272-U}}</ref><ref name="Pickering1981">{{cite journal|last1=Pickering|first1=D|title=Precordial catch syndrome.|journal=Archives of Disease in Childhood|volume=56|issue=5|year=1981|pages=401–403|issn=0003-9888|doi=10.1136/adc.56.5.401}}</ref><ref name="pmid1518687">{{cite journal |vauthors=Wiens L, Sabath R, Ewing L, Gowdamarajan R, Portnoy J, Scagliotti D |title=Chest pain in otherwise healthy children and adolescents is frequently caused by exercise-induced asthma |journal=Pediatrics |volume=90 |issue=3 |pages=350–3 |date=September 1992 |pmid=1518687 |doi= |url=}}</ref><ref name="EvangelistaParsons2000">{{cite journal|last1=Evangelista|first1=Juli-anne K.|last2=Parsons|first2=Marytheresa|last3=Renneburg|first3=Anne K.|title=Chest pain in children: diagnosis through history and physical examination|journal=Journal of Pediatric Health Care|volume=14|issue=1|year=2000|pages=3–8|issn=08915245|doi=10.1016/S0891-5245(00)70037-X}}</ref><ref name="BarthRoberts1986">{{cite journal|last1=Barth|first1=Charles W.|last2=Roberts|first2=William C.|title=Left main coronary artery originating from the right sinus of valsalva and coursing between the aorta and pulmonary trunk|journal=Journal of the American College of Cardiology|volume=7|issue=2|year=1986|pages=366–373|issn=07351097|doi=10.1016/S0735-1097(86)80507-1}}</ref><ref name="LipsitzMasia2005">{{cite journal|last1=Lipsitz|first1=Joshua D.|last2=Masia|first2=Carrie|last3=Apfel|first3=Howard|last4=Marans|first4=Zvi|last5=Gur|first5=Merav|last6=Dent|first6=Heather|last7=Fyer|first7=Abby J.|title=Noncardiac chest pain and psychopathology in children and adolescents|journal=Journal of Psychosomatic Research|volume=59|issue=3|year=2005|pages=185–188|issn=00223999|doi=10.1016/j.jpsychores.2005.05.004}}</ref><ref name="LeeGilleland2013">{{cite journal|last1=Lee|first1=Jennifer L.|last2=Gilleland|first2=Jordan|last3=Campbell|first3=Robert M.|last4=Simpson|first4=Patricia|last5=Johnson|first5=Gregory L.|last6=Dooley|first6=Kenneth J.|last7=Blount|first7=Ronald L.|title=Health care utilization and psychosocial factors in pediatric noncardiac chest pain.|journal=Health Psychology|volume=32|issue=3|year=2013|pages=320–327|issn=1930-7810|doi=10.1037/a0027806}}</ref><ref name="pmid2403723">{{cite journal |vauthors=Selbst SM |title=Chest pain in children |journal=Am Fam Physician |volume=41 |issue=1 |pages=179–86 |date=January 1990 |pmid=2403723 |doi= |url=}}</ref><ref>{{cite journal|doi=10.7759/2Fcureus.3690}}</ref><ref>{{cite journal|doi=10.2147/2FOAEM.S29942}}</ref><ref>{{cite journal|doi=10.1007/2Fs00383-011-2874-8}}</ref><ref name="pmid26692880">{{cite journal |vauthors=Chun JH, Kim TH, Han MY, Kim NY, Yoon KL |title=Analysis of clinical characteristics and causes of chest pain in children and adolescents |journal=Korean J Pediatr |volume=58 |issue=11 |pages=440–5 |date=November 2015 |pmid=26692880 |pmc=4675925 |doi=10.3345/kjp.2015.58.11.440 |url=}}</ref><ref>{{cite journal|doi=10.1161/2FCIRCULATIONAHA.113.006702}}</ref><ref name="Swap2005">{{cite journal|last1=Swap|first1=Clifford J.|title=Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes|journal=JAMA|volume=294|issue=20|year=2005|pages=2623|issn=0098-7484|doi=10.1001/jama.294.20.2623}}</ref>


'''Non Cardiac Causes:'''
{| class="wikitable"
|+
|-
| align="center" style="background: #4479BA; color: #FFFFFF " |'''Causes of pediatric [[chest pain]]'''
|-
|'''[[Musculoskeletal]]'''
|-
|
*[[Costochondritis]]
|-
|
*[[Trauma]]
|-
|
*Muscle overuse/strain
|-
|
*[[Tietze's syndrome]]
|-
|
*[[Precordial catch syndrome]]
|-
|'''[[Respiratory]]'''
|-
|
*Severe and/or chronic [[Cough]]
|-
|
*[[Asthma]] (including [[exercise-induced asthma]])/[[bronchospasm]]
|-
|
*Foreign body
|-
|
*[[Pleuritic]]:
**[[Pneumonia]]
**[[Pneumothorax]]
**[[Pulmonary emboli]]
|-
|'''[[Psychogenic]]'''
|-
|
*[[Anxiety]]
|-
|
*[[Hyperventilation]]
|-
|'''[[Gastrointestinal]]'''
|-
|
*[[Gastroesophageal reflux disease]] ([[GERD]])
|-
|
*[[Esophagitis]]
|-
|
*[[Peptic ulcer disease]]
|-
|'''[[Cardiac]]'''
|-
|
*[[Myocarditis]]
|-
|
*[[Pericarditis]]
|-
|
*[[Arrhythmia]]
|-
|
*[[Myocardial ischemia]]:
**Anomalous coronary arteries
**[[Aortic stenosis]]
**[[Hypertrophic obstructive cardiomyopathy]]
**[[Coronary artery disease]]
**[[vasculitis]]:
***[[Kawasaki disease]]
|-
|
*[[Mitral valve prolapse]]
|-
|'''[[Miscellaneous]]'''
|-
|
*[[Herpes Zoster]]
|-
|
*[[Sickle cell vaso-occlusive crisis]] ([[Acute chest syndrome]])
|-
|
*Tumors (chest wall/mediastinal)
|-
|'''[[Idiopathic]]'''
|-
|}
{|
|-
|}


Idiopathic
''For a complete list of causes of [[chest pain in children]] click [[Chest pain resident survival guide (pediatrics)|here]].''


Musculoskeletal
==Differentiating pediatric chest pain from other Diseases==
*When evaluating pediatric chest pain, serious or life-threatening conditions must be differentiated from benign causes.
*Serious or life-threatening causes of [[chest pain]] in children include: <ref name="pmid20653703">{{cite journal| author=Kane DA, Fulton DR, Saleeb S, Zhou J, Lock JE, Geggel RL| title=Needles in hay: chest pain as the presenting symptom in children with serious underlying cardiac pathology. | journal=Congenit Heart Dis | year= 2010 | volume= 5 | issue= 4 | pages= 366-73 | pmid=20653703 | doi=10.1111/j.1747-0803.2010.00436.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20653703  }} </ref> <ref name="pmid23769502">{{cite journal |vauthors=Friedman KG, Alexander ME |title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease |journal=J Pediatr |volume=163 |issue=3 |pages=896–901.e1–3 |date=September 2013 |pmid=23769502 |pmc=3982288 |doi=10.1016/j.jpeds.2013.05.001 |url=}}</ref><ref name="pmid1697801">{{cite journal |vauthors=Aeschlimann A, Kahn MF |title=Tietze's syndrome: a critical review |journal=Clin Exp Rheumatol |volume=8 |issue=4 |pages=407–12 |date=1990 |pmid=1697801 |doi= |url=}}</ref><ref name="Heinz1977">{{cite journal|last1=Heinz|first1=George J.|title=Slipping Rib Syndrome|journal=JAMA|volume=237|issue=8|year=1977|pages=794|issn=0098-7484|doi=10.1001/jama.1977.03270350054023}}</ref><ref name="pmid4000782">{{cite journal |vauthors=Selbst SM |title=Chest pain in children |journal=Pediatrics |volume=75 |issue=6 |pages=1068–70 |date=June 1985 |pmid=4000782 |doi= |url=}}</ref><ref name="Howell1992">{{cite journal|last1=Howell|first1=John M.|title=Xiphodynia: A report of three cases|journal=The Journal of Emergency Medicine|volume=10|issue=4|year=1992|pages=435–438|issn=07364679|doi=10.1016/0736-4679(92)90272-U}}</ref><ref name="Pickering1981">{{cite journal|last1=Pickering|first1=D|title=Precordial catch syndrome.|journal=Archives of Disease in Childhood|volume=56|issue=5|year=1981|pages=401–403|issn=0003-9888|doi=10.1136/adc.56.5.401}}</ref><ref name="pmid1518687">{{cite journal |vauthors=Wiens L, Sabath R, Ewing L, Gowdamarajan R, Portnoy J, Scagliotti D |title=Chest pain in otherwise healthy children and adolescents is frequently caused by exercise-induced asthma |journal=Pediatrics |volume=90 |issue=3 |pages=350–3 |date=September 1992 |pmid=1518687 |doi= |url=}}</ref><ref name="EvangelistaParsons2000">{{cite journal|last1=Evangelista|first1=Juli-anne K.|last2=Parsons|first2=Marytheresa|last3=Renneburg|first3=Anne K.|title=Chest pain in children: diagnosis through history and physical examination|journal=Journal of Pediatric Health Care|volume=14|issue=1|year=2000|pages=3–8|issn=08915245|doi=10.1016/S0891-5245(00)70037-X}}</ref><ref name="BarthRoberts1986">{{cite journal|last1=Barth|first1=Charles W.|last2=Roberts|first2=William C.|title=Left main coronary artery originating from the right sinus of valsalva and coursing between the aorta and pulmonary trunk|journal=Journal of the American College of Cardiology|volume=7|issue=2|year=1986|pages=366–373|issn=07351097|doi=10.1016/S0735-1097(86)80507-1}}</ref><ref name="LipsitzMasia2005">{{cite journal|last1=Lipsitz|first1=Joshua D.|last2=Masia|first2=Carrie|last3=Apfel|first3=Howard|last4=Marans|first4=Zvi|last5=Gur|first5=Merav|last6=Dent|first6=Heather|last7=Fyer|first7=Abby J.|title=Noncardiac chest pain and psychopathology in children and adolescents|journal=Journal of Psychosomatic Research|volume=59|issue=3|year=2005|pages=185–188|issn=00223999|doi=10.1016/j.jpsychores.2005.05.004}}</ref><ref name="LeeGilleland2013">{{cite journal|last1=Lee|first1=Jennifer L.|last2=Gilleland|first2=Jordan|last3=Campbell|first3=Robert M.|last4=Simpson|first4=Patricia|last5=Johnson|first5=Gregory L.|last6=Dooley|first6=Kenneth J.|last7=Blount|first7=Ronald L.|title=Health care utilization and psychosocial factors in pediatric noncardiac chest pain.|journal=Health Psychology|volume=32|issue=3|year=2013|pages=320–327|issn=1930-7810|doi=10.1037/a0027806}}</ref><ref name="pmid2403723">{{cite journal |vauthors=Selbst SM |title=Chest pain in children |journal=Am Fam Physician |volume=41 |issue=1 |pages=179–86 |date=January 1990 |pmid=2403723 |doi= |url=}}</ref><ref>{{cite journal|doi=10.7759/2Fcureus.3690}}</ref><ref>{{cite journal|doi=10.2147/2FOAEM.S29942}}</ref><ref>{{cite journal|doi=10.1007/2Fs00383-011-2874-8}}</ref><ref name="pmid26692880">{{cite journal |vauthors=Chun JH, Kim TH, Han MY, Kim NY, Yoon KL |title=Analysis of clinical characteristics and causes of chest pain in children and adolescents |journal=Korean J Pediatr |volume=58 |issue=11 |pages=440–5 |date=November 2015 |pmid=26692880 |pmc=4675925 |doi=10.3345/kjp.2015.58.11.440 |url=}}</ref><ref>{{cite journal|doi=10.1161/2FCIRCULATIONAHA.113.006702}}</ref><ref name="Swap2005">{{cite journal|last1=Swap|first1=Clifford J.|title=Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes|journal=JAMA|volume=294|issue=20|year=2005|pages=2623|issn=0098-7484|doi=10.1001/jama.294.20.2623}}</ref>
**[[Aortic dissection]]
**Foreign body aspiration or ingestion
**[[Myocardial ischemia]]
**[[Myocarditis]]
**[[Pericarditis]]
**[[Pericardial effusion]]
**[[Pneumothorax]]/[[tension pneumothorax]]
**[[Pulmonary embolus]]
**[[Status asthmatics]]


#Muscle strain
==Epidemiology and Demographics==
#Trauma
*Chest pain accounts for 0.3%-0.6% of emergency department visits,  15% of outpatient visits, and 5.2% of cardiology consultations in the pediatric population. <ref name="pmid26678235">{{cite journal| author=Yeh TK, Yeh J| title=Chest Pain in Pediatrics. | journal=Pediatr Ann | year= 2015 | volume= 44 | issue= 12 | pages= e274-8 | pmid=26678235 | doi=10.3928/00904481-20151110-01 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26678235  }} </ref> <ref name="pmid21111115">{{cite journal| author=Selbst SM| title=Approach to the child with chest pain. | journal=Pediatr Clin North Am | year= 2010 | volume= 57 | issue= 6 | pages= 1221-34 | pmid=21111115 | doi=10.1016/j.pcl.2010.09.003 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21111115  }} </ref>
#Costochondritis
*In children and adolescents aged 10-21 years, chest pain has been reported to cause ≥ 650,000 annual pediatric cardiologist visits. <ref name="pmid26678235">{{cite journal| author=Yeh TK, Yeh J| title=Chest Pain in Pediatrics. | journal=Pediatr Ann | year= 2015 | volume= 44 | issue= 12 | pages= e274-8 | pmid=26678235 | doi=10.3928/00904481-20151110-01 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26678235  }} </ref>
#Precordial catch syndrome
 
Respiratory
 
#Asthma
#Pneumonia
#Pneumothorax
#Pulmonary embolism
#Inhaled foreign body.
#Chronic cough


Gastrointestinal
==Risk factors==
Common risk factors in the development of [[chest pain]] in children include:
<ref name="pmid23769502">{{cite journal |vauthors=Friedman KG, Alexander ME |title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease |journal=J Pediatr |volume=163 |issue=3 |pages=896–901.e1–3 |date=September 2013 |pmid=23769502 |pmc=3982288 |doi=10.1016/j.jpeds.2013.05.001 |url=}}</ref><ref name="pmid1697801">{{cite journal |vauthors=Aeschlimann A, Kahn MF |title=Tietze's syndrome: a critical review |journal=Clin Exp Rheumatol |volume=8 |issue=4 |pages=407–12 |date=1990 |pmid=1697801 |doi= |url=}}</ref><ref name="Heinz1977">{{cite journal|last1=Heinz|first1=George J.|title=Slipping Rib Syndrome|journal=JAMA|volume=237|issue=8|year=1977|pages=794|issn=0098-7484|doi=10.1001/jama.1977.03270350054023}}</ref><ref name="pmid4000782">{{cite journal |vauthors=Selbst SM |title=Chest pain in children |journal=Pediatrics |volume=75 |issue=6 |pages=1068–70 |date=June 1985 |pmid=4000782 |doi= |url=}}</ref><ref name="Howell1992">{{cite journal|last1=Howell|first1=John M.|title=Xiphodynia: A report of three cases|journal=The Journal of Emergency Medicine|volume=10|issue=4|year=1992|pages=435–438|issn=07364679|doi=10.1016/0736-4679(92)90272-U}}</ref><ref name="Pickering1981">{{cite journal|last1=Pickering|first1=D|title=Precordial catch syndrome.|journal=Archives of Disease in Childhood|volume=56|issue=5|year=1981|pages=401–403|issn=0003-9888|doi=10.1136/adc.56.5.401}}</ref><ref name="pmid1518687">{{cite journal |vauthors=Wiens L, Sabath R, Ewing L, Gowdamarajan R, Portnoy J, Scagliotti D |title=Chest pain in otherwise healthy children and adolescents is frequently caused by exercise-induced asthma |journal=Pediatrics |volume=90 |issue=3 |pages=350–3 |date=September 1992 |pmid=1518687 |doi= |url=}}</ref><ref name="EvangelistaParsons2000">{{cite journal|last1=Evangelista|first1=Juli-anne K.|last2=Parsons|first2=Marytheresa|last3=Renneburg|first3=Anne K.|title=Chest pain in children: diagnosis through history and physical examination|journal=Journal of Pediatric Health Care|volume=14|issue=1|year=2000|pages=3–8|issn=08915245|doi=10.1016/S0891-5245(00)70037-X}}</ref><ref name="BarthRoberts1986">{{cite journal|last1=Barth|first1=Charles W.|last2=Roberts|first2=William C.|title=Left main coronary artery originating from the right sinus of valsalva and coursing between the aorta and pulmonary trunk|journal=Journal of the American College of Cardiology|volume=7|issue=2|year=1986|pages=366–373|issn=07351097|doi=10.1016/S0735-1097(86)80507-1}}</ref><ref name="LipsitzMasia2005">{{cite journal|last1=Lipsitz|first1=Joshua D.|last2=Masia|first2=Carrie|last3=Apfel|first3=Howard|last4=Marans|first4=Zvi|last5=Gur|first5=Merav|last6=Dent|first6=Heather|last7=Fyer|first7=Abby J.|title=Noncardiac chest pain and psychopathology in children and adolescents|journal=Journal of Psychosomatic Research|volume=59|issue=3|year=2005|pages=185–188|issn=00223999|doi=10.1016/j.jpsychores.2005.05.004}}</ref><ref name="LeeGilleland2013">{{cite journal|last1=Lee|first1=Jennifer L.|last2=Gilleland|first2=Jordan|last3=Campbell|first3=Robert M.|last4=Simpson|first4=Patricia|last5=Johnson|first5=Gregory L.|last6=Dooley|first6=Kenneth J.|last7=Blount|first7=Ronald L.|title=Health care utilization and psychosocial factors in pediatric noncardiac chest pain.|journal=Health Psychology|volume=32|issue=3|year=2013|pages=320–327|issn=1930-7810|doi=10.1037/a0027806}}</ref><ref name="pmid2403723">{{cite journal |vauthors=Selbst SM |title=Chest pain in children |journal=Am Fam Physician |volume=41 |issue=1 |pages=179–86 |date=January 1990 |pmid=2403723 |doi= |url=}}</ref><ref>{{cite journal|doi=10.7759/2Fcureus.3690}}</ref><ref>{{cite journal|doi=10.2147/2FOAEM.S29942}}</ref><ref>{{cite journal|doi=10.1007/2Fs00383-011-2874-8}}</ref><ref name="pmid26692880">{{cite journal |vauthors=Chun JH, Kim TH, Han MY, Kim NY, Yoon KL |title=Analysis of clinical characteristics and causes of chest pain in children and adolescents |journal=Korean J Pediatr |volume=58 |issue=11 |pages=440–5 |date=November 2015 |pmid=26692880 |pmc=4675925 |doi=10.3345/kjp.2015.58.11.440 |url=}}</ref><ref>{{cite journal|doi=10.1161/2FCIRCULATIONAHA.113.006702}}</ref><ref name="Swap2005">{{cite journal|last1=Swap|first1=Clifford J.|title=Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes|journal=JAMA|volume=294|issue=20|year=2005|pages=2623|issn=0098-7484|doi=10.1001/jama.294.20.2623}}</ref>
*Chest trauma
*Muscle overuse/strain
*Prior cardiac disease (including [[congenital heart disease]]) or surgery
*[[Hypercoagulable states]]
*[[Sickle cell disease]]
*Chronic respiratory diseases
*[[Kawasaki disease]]
*[[Familial hyperlipidemia syndromes]]
*[[Substance abuse]] ([[amphetamine]], [[cocaine]], or other stimulants)
*[[Connective tissue diseases]]


#Gastroesophageal reflux( GERD)
==Screening==
#Esophagitis
There is insufficient evidence to recommend routine screening for chest pain in children.
#Gastritis
#Foreign body
 
Miscellaneous
 
#Psychogenic and Anxiety
#Sickle cell disease
#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==
==Natural History, Complications and Prognosis==
*Most cases of chest pain in children are benign, and cardiac causes have been identified in less than 1% of children with chest pain. <ref name="pmid26678235">{{cite journal| author=Yeh TK, Yeh J| title=Chest Pain in Pediatrics. | journal=Pediatr Ann | year= 2015 | volume= 44 | issue= 12 | pages= e274-8 | pmid=26678235 | doi=10.3928/00904481-20151110-01 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26678235  }} </ref> <ref name="pmid24301714">{{cite journal| author=Collins SA, Griksaitis MJ, Legg JP| title=15-minute consultation: a structured approach to the assessment of chest pain in a child. | journal=Arch Dis Child Educ Pract Ed | year= 2014 | volume= 99 | issue= 4 | pages= 122-6 | pmid=24301714 | doi=10.1136/archdischild-2013-303919 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24301714  }} </ref>
*Despite having benign etiologies, chest pain in children may contribute to school absences, activity restrictions, and significant anxiety in children and their families. 
*The complications of chest pain in children depend on the underlying etiology.


*The majority of patients with chest pain have bengin non cardiac causes.
==Diagnosis==
*Prognosis is generally good in non-cardiac causes.
===Diagnostic Study of Choice===
*A thorough [[history]] and [[physical examination]] will reveal the etiology of [[chest pain]] in the majority of children. <ref name="pmid24301714">{{cite journal| author=Collins SA, Griksaitis MJ, Legg JP| title=15-minute consultation: a structured approach to the assessment of chest pain in a child. | journal=Arch Dis Child Educ Pract Ed | year= 2014 | volume= 99 | issue= 4 | pages= 122-6 | pmid=24301714 | doi=10.1136/archdischild-2013-303919 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24301714  }} </ref>


==Diagnosis==
===History and symptoms===
===Symptoms===
*A detailed [[history]] is of crucial importance when assessing a child with [[chest pain]] as it can help to make a definitive diagnosis in most pediatric patients with [[chest pain]]. <ref name="pmid23769502">{{cite journal |vauthors=Friedman KG, Alexander ME |title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease |journal=J Pediatr |volume=163 |issue=3 |pages=896–901.e1–3 |date=September 2013 |pmid=23769502 |pmc=3982288 |doi=10.1016/j.jpeds.2013.05.001 |url=}}</ref><ref>{{cite journal|doi=10.3345/2Fkjp.2015.58.11.440}}</ref><ref name="IvesDaubeney2010">{{cite journal|last1=Ives|first1=A.|last2=Daubeney|first2=P. E. F.|last3=Balfour-Lynn|first3=I. M.|title=Recurrent chest pain in the well child|journal=Archives of Disease in Childhood|volume=95|issue=8|year=2010|pages=649–654|issn=0003-9888|doi=10.1136/adc.2008.155309}}</ref><ref name="pmid24301714">{{cite journal| author=Collins SA, Griksaitis MJ, Legg JP| title=15-minute consultation: a structured approach to the assessment of chest pain in a child. | journal=Arch Dis Child Educ Pract Ed | year= 2014 | volume= 99 | issue= 4 | pages= 122-6 | pmid=24301714 | doi=10.1136/archdischild-2013-303919 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24301714  }} </ref>
Symptoms of chest pain may include the following:
*Particular attention should be paid to the nature of the pain, its characteristics, and associated [[symptom]]s.
*Younger children may interpret a wide range of [[symptom]]s and even unpleasant sensations in their chest wall as [[chest pain]]. A thorough [[history]] may help differentiate true chest pain from these unusual sensations. 
*The important characteristics of [[chest pain]] that can help to differentiate the underlying etiology are:
===== [[Musculoskeletal]]  =====
*Usually well-localized
*Associated with chest wall [[tenderness]], i.e., reproducible with palpation or gentle pressure
*Worse with movement, [[coughing]], and [[inspiration]]
===== [[Respiratory]] =====
*[[Chest pain]] from [[asthma]] is often interpreted as ‘tightness’. Associated symptoms include [[dyspnea]] ([[shortness of breath]]), [[wheezing]], and dry [[cough]]. In patients with [[exertion-induced asthma]], [[symptom]]s are precipitated with physical activity.
*[[Pleuritic chest pain]] is usually sharp and localized, and positional, i.e., aggravated by [[inspiration]] and [[coughing]]. It may be seen in patients with [[pneumothorax]] and [[pulmonary emboli]]. 
===== [[Psychogenic]] =====
*History of [[anxiety disorders]] (e.g. [[panic disorder]]) and/or recent stressful life events.
*[[Hyperventilation]] is a common associated symptom.
===== [[Gastrointestinal]] =====
*[[Retrosternal]] or [[epigastric]] pain
*Typically burning or sharp in nature.
*Eating may exacerbate or improve the pain
*Associates symptoms may include: [[heartburn]], [[dysphagia]], [[nausea]]/[[vomiting]], nocturnal [[cough]]
===== [[Cardiac]] =====
*Usually [[retrosternal]], may radiate to the left arm/jaw region.
*Cardiac [[chest pain]] is typically described as heaviness or crushing pain
*[[Chest pain]] may be precipitated by exertion.
*Associated symptoms include [[presyncope]], [[syncope]], and [[palpitations]].
====== Other important clues in making the diagnosis of [[chest pain]] in children include: ======
*History of underlying medical conditions that may be associated with [[chest pain]] including:
**[[Congenital heart disease]]
**[[Kawasaki disease]]
**[[Sickle cell disease]]
*History of recent [[trauma]], and new or intense physical activity causing muscle overuse/strain
*History or the possibility of recent [[substance abuse]]
*Family history of [[sudden cardiac death]], young-onset [[ischemic heart disease]], and inherited [[arrhythmias]] such as [[long QT syndrome]] or [[Brugada syndrome]]


:*Chest wall pain
:*Dyspnea
:*Cough
:*Heartburn
:*Pain after taking medications
:*Fever
===Physical Examination===
===Physical Examination===
 
*A thorough [[physical examination]] is most often all that is needed to establish a definitive diagnosis in children with [[chest pain]]. <ref name="pmid24301714">{{cite journal| author=Collins SA, Griksaitis MJ, Legg JP| title=15-minute consultation: a structured approach to the assessment of chest pain in a child. | journal=Arch Dis Child Educ Pract Ed | year= 2014 | volume= 99 | issue= 4 | pages= 122-6 | pmid=24301714 | doi=10.1136/archdischild-2013-303919 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24301714  }} </ref>
*Physical examination may reveal:
*Initial assessment should focus on identifying signs of [[cardiorespiratory distress]]. Patients with any of the following findings on [[physical examination]] are more likely to have a serious or life-threatening condition that warrants further diagnostic workup and/or therapeutic intervention:
 
**[[Dyspnea]], [[tachypnea]], increased work of breathing
:*Chest wall tenderness in muscle strain and costochondritis
**[[Hypoxia]]
:*Murmur, gallop, pericardial friction rub, distant heart sounds, and abnormal second heart sound (loud S2)
**Abnormal [[pulse]] or [[blood pressure]]
:*Irregular rhythm,
**Evidence of [[poor perfusion]]/[[shock]]
:*Peripheral edema
**Distended neck veins
:*Cyanosis
**Muffled heart sounds
:*Tachypnea
**Altered mental state
:*Skin rash
**Therefore, a complete [[physical examination]] should include the following:
**Assessment of [[vital signs]], including [[blood pressure]], [[heart rate]], [[respiratory rate]], and [[oxygen saturations]]
**Assessment of general appearance, including the [[level of consciousness]], color (central or peripheral cyanosis), and evidence of [[anxiety]]/distress, [[dyspnea]], [[tachypnea]], increased work of breathing
**Evaluation of [[peripheral pulses]]
**Inspection of the chest for signs of recent trauma, [[bruising]], deformities or asymmetry, [[intercostal retraction]], and localized swelling (in particular at [[costochondral junctions]])
**Palpation of the chest for chest wall tenderness (in particular at the location of pain), [[crepitus]], [[heaves]], or [[thrills]]
***[[Hooking maneuver]]: hook fingers under lower [[costal margin]] and pull anteriorly- this maneuver will reproduce pain in patients with [[slipping rib syndrome]].
**[[Auscultation]] of lung fields for [[breath sounds]], [[wheeze]], [[crackles]], and [[pleural rub]]. Assessment of [[tactile fremitus]] and transmitted voice sounds ([[egophony]], [[bronchophony]], [[whispered pectoriloquy]]) may be done if there is a clinical suspicion of pulmonary diseases
**[[Auscultation]] of [[precordium]] for [[heart sounds]], [[murmurs]], and [[pericardial rub]]
**Examination of the abdomen for signs of [[tenderness]] (in particular at [[epigastric]] region)


===Laboratory Findings===
===Laboratory Findings===
 
*Laboratory testing is rarely needed in pediatric patients presenting with [[chest pain]]. <ref name="pmid23769502">{{cite journal| author=Friedman KG, Alexander ME| title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. | journal=J Pediatr | year= 2013 | volume= 163 | issue= 3 | pages= 896-901.e1-3 | pmid=23769502 | doi=10.1016/j.jpeds.2013.05.001 | pmc=3982288 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23769502  }} </ref>
*Cardiac troponin
*Cardiac [[troponins]] and [[CK-MB]] may be indicated in patients suspected of having cardiac diseases such as [[myocardial infarction]] and [[myocarditis]].
*CBC
*Additional laboratory tests include [[serum electrolytes]], a [[complete blood count]], [[renal function tests]], and [[liver function tests]].
*CRP
*ESR


===Electrocardiogram===
===Electrocardiogram===
An ECG should be obtained if a cardiac disease is suspected and when a noncardiac etiology is not clear.
An [[electrocardiogram]] ([[ECG]]) should be obtained if there is a clinical suspicion of [[cardiac disease]] based upon [[history]] or[[ physical examination]] findings. <ref name="pmid23769502">{{cite journal| author=Friedman KG, Alexander ME| title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. | journal=J Pediatr | year= 2013 | volume= 163 | issue= 3 | pages= 896-901.e1-3 | pmid=23769502 | doi=10.1016/j.jpeds.2013.05.001 | pmc=3982288 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23769502  }} </ref>
 
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===
===X-ray===
An x-ray may be helpful in the diagnosis of the cause of chest pain.  
*A [[chest X-ray]] should be obtained in children in whom a cardiac or pulmonary disorder or foreign body ingestion/or aspiration is suspected based on history and physical examination. <ref name="pmid23769502">{{cite journal| author=Friedman KG, Alexander ME| title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. | journal=J Pediatr | year= 2013 | volume= 163 | issue= 3 | pages= 896-901.e1-3 | pmid=23769502 | doi=10.1016/j.jpeds.2013.05.001 | pmc=3982288 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23769502  }} </ref>
 
*Useful [[x-ray]] findings and relevant underlying conditions include:
The x-ray may show:
*Signs of [[cardiac enlargement]]: [[heart failure]], [[myocarditis]], [[pericarditis]], or [[pericardial effusion]]
 
*Enlarged [[aortic root]]: [[aortic dissection]]
*Cardiac enlargement in myocarditis and pericardial effusion
*Prominent main [[pulmonary arteries]]: [[pulmonary hypertension]]
*Prominent main and central pulmonary arteries. in pulmonary hypertension
*[[Lobar Consolidation]]: pneumonia  
*infiltrates in pneumonia
*Areas of [[atelectasis]] and [[air trapping]]: [[foreign body aspiration]]
*atelectasis
*[[Hyperinflation]]: [[asthma]]
*Hyperinflation in asthma.
*In addition, [[chest X-ray]] can detect:
*Pneumothorax, pneumomediastinum, or pleural effusions.
**Radio-opaque foreign bodies (eg, button battery, coin, or magnet)
*Radio-opaque esophageal foreign body (eg, button battery, or coin).
**[[Pneumothorax]]
*
**[[Pneumomediastinum]]
**[[Pleural effusions]]


===Echocardiography or Ultrasound===
===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.
*In patients with clinical suspicion of cardiac disease, an echocardiographic examination is indicated. [[Echocardiography]] may be helpful in: <ref name="pmid23769502">{{cite journal| author=Friedman KG, Alexander ME| title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. | journal=J Pediatr | year= 2013 | volume= 163 | issue= 3 | pages= 896-901.e1-3 | pmid=23769502 | doi=10.1016/j.jpeds.2013.05.001 | pmc=3982288 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23769502 }} </ref>
 
**Evaluating cardiac structural abnormalities, and [[ventricular function]]
-Echocardiography is indicated in the patients with the following:
**Evaluating valvular structure and function
 
**Measurement of [[pulmonary artery pressure]] and establishing the diagnosis of [[pulmonary hypertension]]
*Exertional chest pain or syncope.
**Assessment of the presence and the size of [[pericardial effusion]] and evaluating the signs of [[tamponade]] (including variation in Doppler peak velocity across the valves during the cardiac cycle, atrial free wall collapse, or paradoxical motion of ventricular septum into the left ventricle during inspiration)
*Chest pain associated with fever.
**Diagnosing coronary artery abnormalities, including abnormal origin or course, fistula, aneurysm, and stenosis (caused by [[Kawasaki disease]])
*History of congenital heart disease, Kawasaki syndrome, or diseases that raise cardiac risk (eg, malignancy, hypercoagulable state).
**Diagnosing [[aortic root dissection]]
*Family history of cardiomyopathy, sudden death.
*In clinically unstable patients, ultrasound may help in the diagnosis of [[pneumothorax]] and [[pericardial effusion]]s and guide interventions (eg, [[chest tube thoracostomy]] or [[pericardiocentesis]]
*New murmur
*Distant heart sounds
*Pericardial friction rub
*Loud S2
*Peripheral edema
*Abnormal electrocardiogram.


===CT scan===
===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.
*A CT scan may be helpful in the diagnosis of several [[cardiac diseases]], [[pulmonary diseases]], and foreign body ingestion/aspiration.


===MRI===
===MRI===
MRI scan may be helpful in the diagnosis of the cause of chest pain, including myocarditis, Arrhythmogenic right ventricular dysplasia (ARVD), and tumors.
*A MRI may be helpful in the diagnosis of acute [[aortic dissection]].


===Other Diagnostic Studies===
===Other Diagnostic Studies===
Holter monitoring to diagnose arrhythmia as a cause of intermittent chest pain.
*A [[24-hour ECG Holter monitoring]] may be used to diagnose [[arrhythmia]]. <ref name="pmid23769502">{{cite journal| author=Friedman KG, Alexander ME| title=Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. | journal=J Pediatr | year= 2013 | volume= 163 | issue= 3 | pages= 896-901.e1-3 | pmid=23769502 | doi=10.1016/j.jpeds.2013.05.001 | pmc=3982288 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23769502  }} </ref>
*Other imaging studies that may be used in the evaluation of [[chest pain]] include [[V/Q scintigraphy]], [[CT angiography]], and [[upper GI endoscopy]].
 
''*For an algorithmic guide on the diagnosis of chest pain in children, [[Chest pain resident survival guide (pediatrics)|click here]].<br />''


==Treatment==
==Treatment==
===Medical Therapy===
===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).
''*For a complete guide on the algorithmic approach to the treatment of chest pain in children, [[Chest pain resident survival guide (pediatrics)|click here]].<br />
*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]]).
*Medical management of stable patients depends on the underlying etiology of [[chest pain]]: <ref>{{cite journal|doi=10.1136/2Fadc.63.12.1457}}</ref>
*[[Costochondritis]] and muscle strain can be treated with [[rest]], [[warm compression]], [[analgesic]], anti-inflammatory agents ([[NSAID]]s)
*[[Pneumonia]] can be treated with [[antibiotics]], [[supplemental oxygen]], and [[mechanical ventilation]] as needed
*[[Gastroesophageal reflux disease]] can be treated with [[H2-blockers]] and [[proton pump inhibitors]] ([[PPIs]]
**For a complete guide on the treatments of [[GERD]], [[Gastroesophageal reflux disease medical therapy|click here]]<br />
*[[Acute chest syndrome]] in patients with [[sickle cell disease]] may be managed with pain control, [[antibiotics]], [[hydration]], [[blood transfusion]], or [[exchange transfusion]]
**For a complete guide on the treatments of [[acute chest syndrome]], [[Acute chest syndrome medical therapy|click here]]<br />
*[[Pulmonary embolism]] requires [[anticoagulant therapy]] or [[thrombolytic]] in hemodynamically unstable children
**For a complete guide on the treatments of [[pulmonary embolism]], [[Pulmonary embolism treatment approach|click here]]<br />
*[[Myocardial ischemia]] and [[myocardial infarction]] should receive anticoagulation, pain management, and catheterization
*[[Heart failure]] should be managed with [[diuretics]], [[ACEIs]], and [[beta-blockers]] if no contraindications
*[[Tachyarrhythmias]] should be managed according to [[Pediatric Advanced Life Support]] ([[PALS]])
*[[Pericarditis]] with [[pericardial effusio]]n requires [[pericardiocentesis]] in patients with [[tamponade]]
**For a complete guide on the treatments of [[pericarditis]], [[Pericarditis treatment|click here]]<br />


The medical management of stable patients differs according to the cause:
===Surgery===
Surgical intervention may be indicated in patients with: <ref name="pmid29963100">{{cite journal| author=Govindarajan KK| title=Esophageal perforation in children: etiology and management, with special reference to endoscopic esophageal perforation. | journal=Korean J Pediatr | year= 2018 | volume= 61 | issue= 6 | pages= 175-179 | pmid=29963100 | doi=10.3345/kjp.2018.61.6.175 | pmc=6021361 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29963100  }} </ref> <ref name="pmid17007168">{{cite journal| author=Fikar CR| title=Acute aortic dissection in children and adolescents: diagnostic and after-event follow-up obligation to the patient and family. | journal=Clin Cardiol | year= 2006 | volume= 29 | issue= 9 | pages= 383-6 | pmid=17007168 | doi=10.1002/clc.4960290903 | pmc=6654457 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17007168  }} </ref> <ref name="pmid30592692">{{cite journal| author=Williams K, Baumann L, Grabowski J, Lautz TB| title=Current Practice in the Management of Spontaneous Pneumothorax in Children. | journal=J Laparoendosc Adv Surg Tech A | year= 2019 | volume= 29 | issue= 4 | pages= 551-556 | pmid=30592692 | doi=10.1089/lap.2018.0629 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30592692  }} </ref> <ref name="pmid32167851">{{cite journal| author=Pogorelić Z, Gudelj R, Bjelanović D, Jukić M, Elezović Baloević S, Glumac S | display-authors=etal| title=Management of the Pediatric Spontaneous Pneumothorax: The Role of Video-Assisted Thoracoscopic Surgery. | journal=J Laparoendosc Adv Surg Tech A | year= 2020 | volume= 30 | issue= 5 | pages= 569-575 | pmid=32167851 | doi=10.1089/lap.2019.0742 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32167851  }} </ref>
*[[Aortic dissection]]
*[[Pneumothorax]]
*[[Pericardial effusion]]
*Esophageal foreign body
* Pulmonary foreign body


*Costochondritis and ms strain can be treated with NSAIDs and muscle relaxants.
===Primary Prevention===
*Infections like pneumonia can be treated with antibiotics, supplemental oxygen, and mechanical ventilation as needed
There are no established measures for the primary prevention of [[chest pain]] in children.
*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.
===Secondary Prevention===
*Tension pneumothorax requires a needle or chest tube thoracostomy.
*High-dose [[aspirin]] (80–100 mg/kg/day) and high-dose [[intravenous immunoglobulin]] ([[IVIG]], 2 g/kg) have been suggested to decrease the rate of [[coronary artery aneurysm]]s in children with [[Kawasaki disease]]. <ref name="pmid24730626">{{cite journal| author=Research Committee of the Japanese Society of Pediatric Cardiology. Cardiac Surgery Committee for Development of Guidelines for Medical Treatment of Acute Kawasaki Disease| title=Guidelines for medical treatment of acute Kawasaki disease: report of the Research Committee of the Japanese Society of Pediatric Cardiology and Cardiac Surgery (2012 revised version). | journal=Pediatr Int | year= 2014 | volume= 56 | issue= 2 | pages= 135-58 | pmid=24730626 | doi=10.1111/ped.12317 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24730626  }} </ref>
*Airway foreign body with obstruction requires emergent securing of the airway and bronchoscopy.
*[[Hydroxyurea]], [[chronic transfusion therapy]], and [[L-glutamine]] may decrease the frequency of acute painful [[vaso-occlusive episodes]], including [[acute chest syndrome]], in patients with [[sickle cell disease]]. <ref name="pmid23861242">{{cite journal| author=Alvarez O, Yovetich NA, Scott JP, Owen W, Miller ST, Schultz W | display-authors=etal| title=Pain and other non-neurological adverse events in children with sickle cell anemia and previous stroke who received hydroxyurea and phlebotomy or chronic transfusions and chelation: results from the SWiTCH clinical trial. | journal=Am J Hematol | year= 2013 | volume= 88 | issue= 11 | pages= 932-8 | pmid=23861242 | doi=10.1002/ajh.23547 | pmc=4631259 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23861242  }} </ref> <ref name="pmid30021096">{{cite journal| author=Niihara Y, Miller ST, Kanter J, Lanzkron S, Smith WR, Hsu LL | display-authors=etal| title=A Phase 3 Trial of l-Glutamine in Sickle Cell Disease. | journal=N Engl J Med | year= 2018 | volume= 379 | issue= 3 | pages= 226-235 | pmid=30021096 | doi=10.1056/NEJMoa1715971 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30021096  }} </ref>
*Esophageal foreign body: management depends on the type of body. sharp foreign bodies, impacted batteries, or magnets require urgent removal.


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


[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:Primary care]]
[[Category:Primary care]]
[[Category:Cardiology]]
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Latest revision as of 18:08, 16 April 2021
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mitra Chitsazan, M.D.[2]

Synonyms and keywords: Chest pain in kids, pediatric chest pain

Overview

Chest pain is a common symptom in children and adolescents. Despite causing considerable concerns and anxiety in patients and their families, most cases have benign and non-cardiac etiologies. A thorough history and physical examination can reveal diagnoses in the majority of patients, necessitating laboratory testing and imaging studies only in a small subset of patients.

Historical Perspective

There is limited evidence on the historical perspective of chest pain in children.

Classification

There is no established system for the classification of chest pain in the pediatric population.

Pathophysiology

Causes

The most common causes of chest pain in children include musculoskeletal, respiratory, psychogenic, and idiopathic. A comprehensive list of causes of chest pain in children is presented in the table below: [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]

Causes of pediatric chest pain
Musculoskeletal
  • Muscle overuse/strain
Respiratory
  • Severe and/or chronic Cough
  • Foreign body
Psychogenic
Gastrointestinal
Cardiac
Miscellaneous
  • Tumors (chest wall/mediastinal)
Idiopathic

For a complete list of causes of chest pain in children click here.

Differentiating pediatric chest pain from other Diseases

Epidemiology and Demographics

  • Chest pain accounts for 0.3%-0.6% of emergency department visits, 15% of outpatient visits, and 5.2% of cardiology consultations in the pediatric population. [24] [25]
  • In children and adolescents aged 10-21 years, chest pain has been reported to cause ≥ 650,000 annual pediatric cardiologist visits. [24]

Risk factors

Common risk factors in the development of chest pain in children include: [1][2][3][4][5][6][7][8][9][10][11][12][26][27][28][16][29][18]

Screening

There is insufficient evidence to recommend routine screening for chest pain in children.

Natural History, Complications and Prognosis

  • Most cases of chest pain in children are benign, and cardiac causes have been identified in less than 1% of children with chest pain. [24] [30]
  • Despite having benign etiologies, chest pain in children may contribute to school absences, activity restrictions, and significant anxiety in children and their families.
  • The complications of chest pain in children depend on the underlying etiology.

Diagnosis

Diagnostic Study of Choice

History and symptoms

  • A detailed history is of crucial importance when assessing a child with chest pain as it can help to make a definitive diagnosis in most pediatric patients with chest pain. [1][31][32][30]
  • Particular attention should be paid to the nature of the pain, its characteristics, and associated symptoms.
  • Younger children may interpret a wide range of symptoms and even unpleasant sensations in their chest wall as chest pain. A thorough history may help differentiate true chest pain from these unusual sensations.
  • The important characteristics of chest pain that can help to differentiate the underlying etiology are:
Musculoskeletal
  • Usually well-localized
  • Associated with chest wall tenderness, i.e., reproducible with palpation or gentle pressure
  • Worse with movement, coughing, and inspiration
Respiratory
Psychogenic
Gastrointestinal
Cardiac
Other important clues in making the diagnosis of chest pain in children include:

Physical Examination

Laboratory Findings

Electrocardiogram

An electrocardiogram (ECG) should be obtained if there is a clinical suspicion of cardiac disease based upon history orphysical examination findings. [1]

X-ray

Echocardiography or Ultrasound

CT scan

MRI

Other Diagnostic Studies

*For an algorithmic guide on the diagnosis of chest pain in children, click here.

Treatment

Medical Therapy

*For a complete guide on the algorithmic approach to the treatment of chest pain in children, click here.

Surgery

Surgical intervention may be indicated in patients with: [34] [35] [36] [37]

Primary Prevention

There are no established measures for the primary prevention of chest pain in children.

Secondary Prevention

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Friedman KG, Alexander ME (September 2013). "Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease". J Pediatr. 163 (3): 896–901.e1–3. doi:10.1016/j.jpeds.2013.05.001. PMC 3982288. PMID 23769502.
  2. ↑ 2.0 2.1 2.2 Aeschlimann A, Kahn MF (1990). "Tietze's syndrome: a critical review". Clin Exp Rheumatol. 8 (4): 407–12. PMID 1697801.
  3. ↑ 3.0 3.1 3.2 Heinz, George J. (1977). "Slipping Rib Syndrome". JAMA. 237 (8): 794. doi:10.1001/jama.1977.03270350054023. ISSN 0098-7484.
  4. ↑ 4.0 4.1 4.2 Selbst SM (June 1985). "Chest pain in children". Pediatrics. 75 (6): 1068–70. PMID 4000782.
  5. ↑ 5.0 5.1 5.2 Howell, John M. (1992). "Xiphodynia: A report of three cases". The Journal of Emergency Medicine. 10 (4): 435–438. doi:10.1016/0736-4679(92)90272-U. ISSN 0736-4679.
  6. ↑ 6.0 6.1 6.2 Pickering, D (1981). "Precordial catch syndrome". Archives of Disease in Childhood. 56 (5): 401–403. doi:10.1136/adc.56.5.401. ISSN 0003-9888.
  7. ↑ 7.0 7.1 7.2 Wiens L, Sabath R, Ewing L, Gowdamarajan R, Portnoy J, Scagliotti D (September 1992). "Chest pain in otherwise healthy children and adolescents is frequently caused by exercise-induced asthma". Pediatrics. 90 (3): 350–3. PMID 1518687.
  8. ↑ 8.0 8.1 8.2 Evangelista, Juli-anne K.; Parsons, Marytheresa; Renneburg, Anne K. (2000). "Chest pain in children: diagnosis through history and physical examination". Journal of Pediatric Health Care. 14 (1): 3–8. doi:10.1016/S0891-5245(00)70037-X. ISSN 0891-5245.
  9. ↑ 9.0 9.1 9.2 Barth, Charles W.; Roberts, William C. (1986). "Left main coronary artery originating from the right sinus of valsalva and coursing between the aorta and pulmonary trunk". Journal of the American College of Cardiology. 7 (2): 366–373. doi:10.1016/S0735-1097(86)80507-1. ISSN 0735-1097.
  10. ↑ 10.0 10.1 10.2 Lipsitz, Joshua D.; Masia, Carrie; Apfel, Howard; Marans, Zvi; Gur, Merav; Dent, Heather; Fyer, Abby J. (2005). "Noncardiac chest pain and psychopathology in children and adolescents". Journal of Psychosomatic Research. 59 (3): 185–188. doi:10.1016/j.jpsychores.2005.05.004. ISSN 0022-3999.
  11. ↑ 11.0 11.1 11.2 Lee, Jennifer L.; Gilleland, Jordan; Campbell, Robert M.; Simpson, Patricia; Johnson, Gregory L.; Dooley, Kenneth J.; Blount, Ronald L. (2013). "Health care utilization and psychosocial factors in pediatric noncardiac chest pain". Health Psychology. 32 (3): 320–327. doi:10.1037/a0027806. ISSN 1930-7810.
  12. ↑ 12.0 12.1 12.2 Selbst SM (January 1990). "Chest pain in children". Am Fam Physician. 41 (1): 179–86. PMID 2403723.
  13. ↑ . doi:10.7759/2Fcureus.3690. Missing or empty |title= (help)
  14. ↑ . doi:10.2147/2FOAEM.S29942. Missing or empty |title= (help)
  15. ↑ . doi:10.1007/2Fs00383-011-2874-8. Missing or empty |title= (help)
  16. ↑ 16.0 16.1 16.2 Chun JH, Kim TH, Han MY, Kim NY, Yoon KL (November 2015). "Analysis of clinical characteristics and causes of chest pain in children and adolescents". Korean J Pediatr. 58 (11): 440–5. doi:10.3345/kjp.2015.58.11.440. PMC 4675925. PMID 26692880.
  17. ↑ . doi:10.1161/2FCIRCULATIONAHA.113.006702. Missing or empty |title= (help)
  18. ↑ 18.0 18.1 18.2 Swap, Clifford J. (2005). "Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes". JAMA. 294 (20): 2623. doi:10.1001/jama.294.20.2623. ISSN 0098-7484.
  19. ↑ Kane DA, Fulton DR, Saleeb S, Zhou J, Lock JE, Geggel RL (2010). "Needles in hay: chest pain as the presenting symptom in children with serious underlying cardiac pathology". Congenit Heart Dis. 5 (4): 366–73. doi:10.1111/j.1747-0803.2010.00436.x. PMID 20653703.
  20. ↑ . doi:10.7759/2Fcureus.3690. Missing or empty |title= (help)
  21. ↑ . doi:10.2147/2FOAEM.S29942. Missing or empty |title= (help)
  22. ↑ . doi:10.1007/2Fs00383-011-2874-8. Missing or empty |title= (help)
  23. ↑ . doi:10.1161/2FCIRCULATIONAHA.113.006702. Missing or empty |title= (help)
  24. ↑ 24.0 24.1 24.2 Yeh TK, Yeh J (2015). "Chest Pain in Pediatrics". Pediatr Ann. 44 (12): e274–8. doi:10.3928/00904481-20151110-01. PMID 26678235.
  25. ↑ Selbst SM (2010). "Approach to the child with chest pain". Pediatr Clin North Am. 57 (6): 1221–34. doi:10.1016/j.pcl.2010.09.003. PMID 21111115.
  26. ↑ . doi:10.7759/2Fcureus.3690. Missing or empty |title= (help)
  27. ↑ . doi:10.2147/2FOAEM.S29942. Missing or empty |title= (help)
  28. ↑ . doi:10.1007/2Fs00383-011-2874-8. Missing or empty |title= (help)
  29. ↑ . doi:10.1161/2FCIRCULATIONAHA.113.006702. Missing or empty |title= (help)
  30. ↑ 30.0 30.1 30.2 30.3 Collins SA, Griksaitis MJ, Legg JP (2014). "15-minute consultation: a structured approach to the assessment of chest pain in a child". Arch Dis Child Educ Pract Ed. 99 (4): 122–6. doi:10.1136/archdischild-2013-303919. PMID 24301714.
  31. ↑ . doi:10.3345/2Fkjp.2015.58.11.440. Missing or empty |title= (help)
  32. ↑ Ives, A.; Daubeney, P. E. F.; Balfour-Lynn, I. M. (2010). "Recurrent chest pain in the well child". Archives of Disease in Childhood. 95 (8): 649–654. doi:10.1136/adc.2008.155309. ISSN 0003-9888.
  33. ↑ . doi:10.1136/2Fadc.63.12.1457. Missing or empty |title= (help)
  34. ↑ Govindarajan KK (2018). "Esophageal perforation in children: etiology and management, with special reference to endoscopic esophageal perforation". Korean J Pediatr. 61 (6): 175–179. doi:10.3345/kjp.2018.61.6.175. PMC 6021361. PMID 29963100.
  35. ↑ Fikar CR (2006). "Acute aortic dissection in children and adolescents: diagnostic and after-event follow-up obligation to the patient and family". Clin Cardiol. 29 (9): 383–6. doi:10.1002/clc.4960290903. PMC 6654457 Check |pmc= value (help). PMID 17007168.
  36. ↑ Williams K, Baumann L, Grabowski J, Lautz TB (2019). "Current Practice in the Management of Spontaneous Pneumothorax in Children". J Laparoendosc Adv Surg Tech A. 29 (4): 551–556. doi:10.1089/lap.2018.0629. PMID 30592692.
  37. ↑ Pogorelić Z, Gudelj R, Bjelanović D, Jukić M, Elezović Baloević S, Glumac S; et al. (2020). "Management of the Pediatric Spontaneous Pneumothorax: The Role of Video-Assisted Thoracoscopic Surgery". J Laparoendosc Adv Surg Tech A. 30 (5): 569–575. doi:10.1089/lap.2019.0742. PMID 32167851 Check |pmid= value (help).
  38. ↑ Research Committee of the Japanese Society of Pediatric Cardiology. Cardiac Surgery Committee for Development of Guidelines for Medical Treatment of Acute Kawasaki Disease (2014). "Guidelines for medical treatment of acute Kawasaki disease: report of the Research Committee of the Japanese Society of Pediatric Cardiology and Cardiac Surgery (2012 revised version)". Pediatr Int. 56 (2): 135–58. doi:10.1111/ped.12317. PMID 24730626.
  39. ↑ Alvarez O, Yovetich NA, Scott JP, Owen W, Miller ST, Schultz W; et al. (2013). "Pain and other non-neurological adverse events in children with sickle cell anemia and previous stroke who received hydroxyurea and phlebotomy or chronic transfusions and chelation: results from the SWiTCH clinical trial". Am J Hematol. 88 (11): 932–8. doi:10.1002/ajh.23547. PMC 4631259. PMID 23861242.
  40. ↑ Niihara Y, Miller ST, Kanter J, Lanzkron S, Smith WR, Hsu LL; et al. (2018). "A Phase 3 Trial of l-Glutamine in Sickle Cell Disease". N Engl J Med. 379 (3): 226–235. doi:10.1056/NEJMoa1715971. PMID 30021096.
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