What are the appropriate evaluation and treatment steps for chest pain in children?

Evaluation and Management of Chest Pain in Children

Most chest pain in children is benign and non-cardiac in origin, with idiopathic (21-59%), respiratory (9-24%), musculoskeletal (7-16%), and psychogenic (17-40%) causes being most common, while cardiac causes account for only 1-4% of cases. 1, 2, 3

Etiology of Chest Pain in Children

Common Causes

• Idiopathic chest pain: Most common cause (21-59%), with no identifiable organic etiology 1
• Respiratory causes (9-24%):
  • Asthma, pneumonia, pneumothorax, pneumomediastinum 1, 2
  • Pneumonia may present with localized pleuritic pain and friction rub 4
  • Air-leak syndromes (pneumothorax/pneumomediastinum) typically present with abrupt, continuous pain of short duration (1-2 days) in older adolescents 2
• Musculoskeletal causes (7-16%):
  • Costochondritis, chest wall strain, trauma 1, 5
  • Often characterized by tenderness of costochondral joints 6
• Psychogenic causes (17-40%):
  • Anxiety disorders, depression, panic attacks 1, 3
  • Associated with smartphone and internet addiction in some cases 3

Less Common Causes

• Cardiac causes (1-4%):
  • Arrhythmias (65% of cardiac causes), congenital heart disease (30%), coronary abnormalities (5%) 2
  • May present with syncope, palpitations, or exercise-induced pain 7
• Gastrointestinal causes (2-7%):
  • Gastroesophageal reflux, esophagitis 1, 2
• Other causes (2-4%):
  • Herpes zoster (pain in dermatomal distribution) 6
  • Chronic recurrent multifocal osteomyelitis (rare) 5

Clinical Evaluation

History - Key Elements

• Pain characteristics:
  • Onset (sudden vs. gradual), duration, location, quality, radiation 6
  • Relationship to respiration, position, activity 4
  • Pleuritic pain (sharp, worsens with breathing) suggests respiratory etiology 4
• Associated symptoms:
  • Fever (suggests infection) 6
  • Dyspnea, cough (suggests respiratory cause) 6, 4
  • Palpitations, dizziness, syncope (suggests cardiac cause) 7
• Red flag symptoms requiring urgent evaluation:
  • Pain that wakes child from sleep 7
  • Exercise-induced pain 7
  • Pain associated with syncope, palpitations, or shortness of breath 7
  • Pain in child with history of cardiac disease or risk factors 7

Physical Examination

• Vital signs: Temperature, heart rate, respiratory rate, blood pressure 6
• Respiratory system:
  • Assess for abnormal breath sounds, decreased breath sounds (pneumothorax), friction rub (pleuritis) 6, 4
• Cardiovascular system:
  • Murmurs, abnormal heart sounds, irregular rhythm 6
• Musculoskeletal system:
  • Chest wall tenderness, reproducible pain with palpation (suggests musculoskeletal origin) 4, 5

Diagnostic Approach

Initial Assessment

• Focused history and physical examination should guide the need for further testing 6
• Most children with chest pain have normal physical findings 1

Laboratory and Imaging Studies

• For most cases with normal exam and no concerning history:

  • Reassurance and follow-up are appropriate without extensive testing 7

• When to obtain further testing (based on concerning features):

  • ECG: For pain with exercise, syncope, palpitations, family history of cardiac disease, or abnormal cardiac exam 7
  • Chest radiograph: For fever, respiratory distress, abnormal breath sounds, trauma, or suspected pneumothorax 7
  • Additional testing as guided by specific concerns:
    • Pulmonary function tests for suspected asthma 1
    • Echocardiogram for suspected cardiac etiology 7

Management Approach

General Principles

• For idiopathic chest pain:
  • Explanation and reassurance can reduce anxiety and decrease symptom severity 1
  • Follow-up to monitor symptoms 7

Specific Management

• Respiratory causes:

  • Bronchodilators for exercise-induced asthma 1
  • Appropriate antibiotics for pneumonia 6
  • Observation or intervention for pneumothorax based on severity 2

• Musculoskeletal causes:

  • Non-steroidal anti-inflammatory medications 1
  • Rest and activity modification 5

• Gastrointestinal causes:

  • Anti-reflux medication for gastroesophageal reflux 1

• Psychogenic causes:

  • Psychological support, counseling 3
  • Treatment of underlying anxiety or depression 3

• Cardiac causes:

  • Prompt referral to pediatric cardiology 2
  • Specific treatment based on underlying condition 2

When to Refer to Emergency Department

• Activate emergency medical services (EMS) for:
  • Severe respiratory distress 6
  • Signs of cardiac compromise (hypotension, irregular rhythm) 6
  • Sudden onset of severe pain with systemic symptoms 6
  • Pain associated with syncope 2

Follow-Up

• Children should be followed until symptoms have resolved 6
• Consider underlying diagnoses (immunodeficiency, congenital anomalies) in cases of recurrent or persistent symptoms 6

Common Pitfalls

• Assuming chest pain in children is cardiac: Most pediatric chest pain is non-cardiac in origin 1, 2
• Excessive testing: Most cases can be diagnosed with careful history and physical examination alone 7
• Missing red flags: Pain that wakes child from sleep, exercise-induced pain, or pain with syncope warrants thorough evaluation 7
• Dismissing psychogenic causes: Anxiety and depression are common causes of chest pain in children and require appropriate intervention 3