What is the appropriate workup for a 7-year-old female pediatric (ped) patient presenting with chest pain?

Evaluation of Chest Pain in a 7-Year-Old Female

The appropriate workup for a 7-year-old female with chest pain should focus primarily on identifying non-cardiac causes, as cardiac etiologies are rare in pediatric patients. Unlike adults, most chest pain in children is benign and non-cardiac in origin 1.

Initial Assessment

History - Key Elements to Obtain:

• Characteristics of pain:
  • Nature (sharp, dull, pressure, stabbing)
  • Onset and duration (sudden vs. gradual, brief vs. persistent)
  • Location and radiation
  • Precipitating factors (exercise, rest, breathing, position changes)
  • Relieving factors
  • Associated symptoms (fever, cough, dyspnea, palpitations, syncope)

Physical Examination:

• Vital signs (heart rate, respiratory rate, blood pressure, temperature)
• Chest wall tenderness
• Respiratory examination (breath sounds, respiratory effort)
• Cardiac examination (murmurs, rhythm, gallops)
• Abdominal examination

Diagnostic Approach

First-Line Investigations:

• Chest radiograph - indicated for most pediatric patients with chest pain to evaluate for pneumonia, pneumothorax, or other pulmonary causes 1
• Electrocardiogram (ECG) - should be performed if:
  • Pain occurs with exercise
  • Pain is associated with syncope or palpitations
  • Family history of sudden cardiac death or cardiomyopathy
  • Abnormal cardiac examination

Additional Testing (Based on Initial Findings):

• Complete blood count - if infection is suspected
• Echocardiogram - only if cardiac etiology is suspected based on history, physical exam, or ECG abnormalities
• Pulmonary function tests - if asthma or other respiratory condition is suspected
• Esophagogastroduodenoscopy - if severe gastroesophageal reflux is suspected

Common Causes of Chest Pain in Pediatric Patients

1. Idiopathic (59.2%) - Most common diagnosis 1
2. Pulmonary causes (24.3%) 1:
   • Asthma
   • Pneumonia
   • Pneumothorax
3. Musculoskeletal (6.7%) 1:
   • Costochondritis
   • Muscle strain
   • Trauma
4. Gastrointestinal (5.8%) 1:
   • Gastroesophageal reflux
   • Esophagitis
5. Cardiac (2.0%) - Rare in children 1
6. Psychogenic - Anxiety, stress

Red Flags Requiring Urgent Evaluation

• Chest pain with exertion
• Chest pain with syncope
• Family history of sudden cardiac death or cardiomyopathy
• Abnormal cardiac examination
• Severe, persistent pain
• Pain associated with respiratory distress
• Fever with chest pain

Management Algorithm

1. Perform focused history and physical examination
2. If any red flags are present → obtain ECG, chest radiograph, and consider cardiology consultation
3. If no red flags but respiratory symptoms → chest radiograph
4. If musculoskeletal tenderness → consider conservative management
5. If GI symptoms predominate → consider GI workup
6. If all initial evaluations are normal → provide reassurance and follow-up

Important Considerations

• Unlike adults, where cardiac causes are common, pediatric chest pain is rarely cardiac in origin
• Extensive laboratory testing is usually unnecessary and costly in pediatric chest pain 2
• Reassurance is an important part of management for idiopathic chest pain
• Follow-up should be arranged if symptoms persist or change in character

Remember that a thorough history and physical examination are usually sufficient to exclude life-threatening causes of chest pain in pediatric patients 2.