What is the appropriate workup for an 8-year-old patient presenting to the Emergency Department (ED) with chest pain and upper back pain when drinking water?

Appropriate Workup for an 8-Year-Old with Chest Pain and Upper Back Pain When Drinking Water

The appropriate workup for an 8-year-old with chest pain and upper back pain when drinking water should focus primarily on non-cardiac causes, as cardiac etiologies are rare in pediatric patients with chest pain.

Initial Assessment

History

• Obtain a focused history including:
  • Characteristics of pain (nature, onset, duration, location, radiation)
  • Precipitating factors (specifically relationship to drinking water)
  • Relieving factors
  • Associated symptoms (dysphagia, regurgitation, cough)
  • Prior episodes and their resolution
  • Family history of cardiac disease
  • Recent trauma or illness

Physical Examination

• Vital signs (heart rate, blood pressure, respiratory rate, temperature)
• Chest wall tenderness assessment
• Cardiac examination (murmurs, gallops, rubs)
• Pulmonary examination (wheezing, crackles, decreased breath sounds)
• Abdominal examination (epigastric tenderness)

Diagnostic Testing

First-Line Testing

• 12-lead ECG should be performed and interpreted within 10 minutes of arrival 1
  • This is essential to rule out rare but serious cardiac causes

Additional Testing Based on Clinical Suspicion

• Chest radiography if:

  • Abnormal pulmonary examination
  • Suspicion of pneumonia, pneumothorax, or foreign body
  • Persistent symptoms despite conservative management

• Consider esophageal causes:

  • Pain with drinking water suggests possible esophageal pathology
  • Consider referral for upper GI evaluation if symptoms persist

Testing That Is Usually NOT Needed

• Cardiac biomarkers (troponin, CK-MB) are rarely indicated in pediatric patients with chest pain unless there are specific concerning features 2, 3
• Advanced cardiac imaging is rarely needed in the initial evaluation

Risk Stratification

Low Risk Features (Most Common in Children)

• Pain that is reproducible with palpation (suggests musculoskeletal origin)
• Pain that is specifically related to swallowing/drinking (suggests esophageal origin)
• Normal ECG
• No family history of early cardiac death or cardiomyopathy
• No syncope with exertion

Features Requiring More Extensive Evaluation

• Exertional chest pain
• Syncope with chest pain
• Family history of sudden cardiac death
• Abnormal ECG findings
• Persistent symptoms despite conservative management

Management Approach

1. For patients with normal ECG and low-risk features:

   • Reassurance and education about benign nature of most pediatric chest pain
   • Trial of antacids if esophageal origin is suspected
   • Follow-up with primary care physician

2. For patients with concerning features:

   • Consider cardiology consultation
   • Additional testing as indicated by clinical findings

Important Considerations

• Chest pain in pediatric patients is common but rarely cardiac in origin 2, 3
• Idiopathic chest pain is the most common diagnosis in children 4
• Chest wall pain (28%), pulmonary causes (19%), and minor trauma (15%) are the most common identifiable causes 3
• Esophageal disorders should be considered when pain is associated with drinking
• Unnecessary testing increases healthcare costs without improving outcomes 3

Clinical Pitfalls to Avoid

• Overutilization of cardiac biomarkers and advanced imaging in low-risk patients
• Failure to consider non-cardiac causes, especially esophageal pathology when symptoms are related to drinking
• Missing rare but serious cardiac conditions by not performing an ECG
• Providing inadequate reassurance to patients and families about the typically benign nature of pediatric chest pain

Remember that while most pediatric chest pain is benign, a structured approach to evaluation ensures that serious conditions are not missed while avoiding unnecessary testing.