What is the appropriate management for a 6-year-old with chest pain following an upper respiratory infection (URI)?

Management of Chest Pain in a 6-Year-Old Following URI

For a 6-year-old with chest pain following an upper respiratory infection, the most appropriate initial management is a thorough clinical assessment focusing on identifying red flags for serious pathology (particularly pneumonia with pleural complications, pneumothorax, or cardiac arrhythmias), followed by targeted investigation only if concerning features are present, as most cases are benign and self-limited. 1, 2, 3

Clinical Assessment Priorities

Key Historical Features to Elicit

• Timing and character of pain: Abrupt onset, continuous pain lasting 1-2 days suggests air-leak syndrome (pneumothorax/pneumomediastinum) in older children 4
• Associated symptoms requiring immediate attention:
  • Syncope combined with chest pain mandates cardiac workup, as this may indicate arrhythmias including atrial flutter 4
  • Fever, tachypnea, or respiratory distress suggests pneumonia with possible pleural complications 5
  • Severe breathlessness indicates potential pneumothorax or significant pleural effusion 5

Physical Examination Focus

• Respiratory findings: Decreased breath sounds, dullness to percussion (pleural effusion), or hyperresonance (pneumothorax) 6
• Cardiac assessment: Arrhythmias, murmurs, or signs of pericarditis 2, 4
• Musculoskeletal examination: Chest wall tenderness suggesting costochondritis (7-16% of cases) 2

Diagnostic Approach Based on Clinical Findings

When Imaging IS Indicated

Chest radiograph should be obtained if any of the following are present 5:

• Persistent fever beyond the typical URI course
• Respiratory distress or tachypnea
• Decreased breath sounds or dullness to percussion
• Abrupt, severe, continuous pain in an older child (to exclude pneumothorax/pneumomediastinum) 4

When Further Cardiac Workup IS Required

ECG and cardiology consultation are essential if 4:

• Syncope accompanies chest pain
• Pain occurs with exertion
• Family history of sudden cardiac death or cardiomyopathy
• Abnormal cardiac examination

Note that cardiac causes account for only 1-4% of pediatric chest pain, but missing these can be life-threatening 2, 3

Management Based on Etiology

If Pleural Infection/Effusion is Identified

• Antipyretics and analgesia are important for patient comfort 5
• Small bore chest drains (including pigtail catheters) should be used if drainage is required, as large bore drains offer no advantage and cause more discomfort 5
• Intrapleural fibrinolytics (urokinase 40,000 units in 40 ml saline twice daily for 3 days for children ≥10 kg) shorten hospital stay for complicated parapneumonic effusions 5
• Chest physiotherapy is NOT beneficial and should not be performed 5

If Musculoskeletal Pain is Suspected

• Trial of non-steroidal anti-inflammatory medication is warranted 2
• Reassurance that this is benign and self-limited 3

If Exercise-Induced Asthma is Suspected

• Therapeutic trial with inhaled bronchodilator 15-20 minutes before exercise 2

Most Likely Scenario: Idiopathic Chest Pain

In the absence of red flags, idiopathic chest pain is the most common diagnosis (21-73.6% of cases) 2, 3, 4. This typically presents as:

• Chronic, intermittent symptoms
• Normal physical examination
• Pain following viral URI due to chest wall inflammation or cough-related muscle strain

Management consists of 3:

• Explanation and reassurance to reduce anxiety
• Avoidance of unnecessary laboratory testing and imaging, which are typically nondiagnostic, costly, and burdensome 3
• Follow-up to ensure symptom resolution and maintain a trusting relationship with the family 3

Critical Pitfalls to Avoid

• Do not dismiss chest pain with syncope as benign without cardiac evaluation, as arrhythmias may present with only these two symptoms 4
• Do not miss pneumomediastinum on chest radiograph, as it requires careful examination for diagnosis 4
• Do not order extensive testing (echocardiography, stress testing, laboratory work) in the absence of concerning history or physical findings, as this increases anxiety and cost without improving outcomes 3
• Do not clamp a bubbling chest drain if one is placed for pleural complications, and immediately unclamp any drain if the patient develops breathlessness or chest pain 5