What should the initial workup include for a child presenting with periodic chest pain who is otherwise well?

Initial Workup for a Child with Periodic Chest Pain Who Is Otherwise Well

For a child presenting with periodic chest pain who is otherwise well, the initial workup should include a focused history, physical examination, and an electrocardiogram (ECG), with additional testing guided by specific findings rather than performed routinely.

Initial Assessment

History

• Obtain detailed pain characteristics including onset, duration, location, quality, and radiation 1
• Assess for exertional component, as exertional chest pain was present in 37% of pediatric patients in one study 2
• Document associated symptoms such as fever, cough, or dysphagia 1
• Inquire about relieving and aggravating factors (e.g., position changes, breathing) 3
• Screen for psychological factors as non-cardiac chest pain is often associated with anxiety or other psychological conditions 3
• Ask about family history of cardiac disease or sudden death 3

Physical Examination

• Measure vital signs including temperature, heart rate, respiratory rate, and blood pressure 1
• Perform cardiovascular examination focusing on murmurs, abnormal heart sounds, and irregular rhythm 1
• Evaluate respiratory system for abnormal breath sounds, decreased breath sounds, and friction rub 1
• Assess musculoskeletal system for chest wall tenderness and reproducible pain with palpation 1
• Examine skin for rashes that might indicate conditions like herpes zoster 3

Diagnostic Testing

First-Line Testing

• Perform 12-lead ECG for all patients with chest pain 2
• Compare with previous ECG if available 3

Additional Testing (Based on Initial Findings)

• If normal history, physical exam, and ECG in an otherwise well child:

  • No further testing is typically needed 2
  • Reassurance and follow-up as needed 4

• If abnormal cardiac exam, concerning history, or abnormal ECG:

  • Echocardiography to assess for structural heart disease 2
  • Consider cardiac monitoring (Holter or event monitor) if arrhythmia is suspected 2

• If respiratory symptoms predominate:

  • Consider chest X-ray to evaluate for pneumonia, pneumothorax, or pneumomediastinum 5

Common Causes to Consider

Musculoskeletal (Most Common Identifiable Cause)

• Costochondritis presents with tenderness of costochondral joints 6
• Pain is often reproducible with palpation 1

Respiratory

• Pneumonia may present with localized pleuritic pain, fever, and abnormal breath sounds 1
• Air-leak syndromes (pneumothorax, pneumomediastinum) typically present with abrupt, continuous pain of short duration in older adolescents 5

Cardiac (Rare but Important)

• Arrhythmias account for approximately 65% of cardiac causes of chest pain in children 5
• Congenital heart disease accounts for approximately 30% of cardiac causes 5

Idiopathic/Psychogenic

• Most pediatric chest pain (73.6% in one study) is idiopathic in origin 5
• Anxiety and other psychological factors should be considered 3

Important Considerations

• Cardiac etiology for chest pain is found in only about 1-2% of pediatric patients 2, 5
• Extensive cardiac workups are rarely necessary and contribute to unnecessary resource use 2
• Using a standardized approach can reduce unnecessary testing by approximately 20% while still identifying all cardiac diagnoses 2
• Patients with combined syncope and chest pain warrant more extensive cardiac evaluation 5

Follow-Up Recommendations

• Follow until symptoms have resolved 1
• Consider referral to appropriate specialist if symptoms persist or worsen 1
• Evaluate for underlying conditions if symptoms are recurrent or persistent 1