What should be done if a child complains of chest pain twice in a day?

Immediate Evaluation and Management of Pediatric Chest Pain

When a child complains of chest pain twice in a day, perform a focused assessment to identify red flags requiring emergency care, but recognize that cardiac causes are exceedingly rare (1-4% of cases) and most children have benign, self-limited conditions. 1, 2, 3

Critical Red Flags Requiring Emergency Evaluation

Activate emergency services immediately if any of these features are present:

• Pain that interrupts normal activity or causes the child to stop what they're doing 4, 5
• Associated symptoms including syncope (fainting), severe shortness of breath, diaphoresis (sweating), nausea/vomiting, or extreme anxiety 6, 4, 5
• Abrupt onset, continuous severe pain lasting 1-2 days, particularly in older adolescents (suggests pneumothorax or pneumomediastinum) 3
• Syncope combined with chest pain (requires cardiac workup to exclude arrhythmias like atrial flutter) 3
• Known cardiac history including congenital heart disease, prior Kawasaki disease, or arrhythmias 6, 3

Focused History to Obtain

Ask specific questions to differentiate benign from serious causes:

• Pain characteristics: Sharp/stabbing suggests musculoskeletal (most common at 76%); crushing/pressure raises cardiac concern 2, 1
• Timing: Pain occurring 15-20 minutes into exercise suggests exercise-induced asthma (12% of cases) 1, 2
• Reproducibility: Pain reproduced by palpation of chest wall indicates costochondritis 2, 7
• Associated respiratory symptoms: Cough, wheezing, or dyspnea suggests pulmonary causes (12-24% of cases) 1
• Gastrointestinal symptoms: Heartburn, regurgitation, or meal-related pain suggests GERD (5-7% of cases) 1

Physical Examination Priorities

Most children with chest pain have completely normal physical findings, but examine for:

• Chest wall tenderness: Palpate costochondral junctions and intercostal spaces (positive in musculoskeletal pain) 2, 7
• Vital signs: Tachycardia and tachypnea may indicate pulmonary embolism (rare in children) or pneumothorax 3
• Cardiac auscultation: New murmurs or abnormal heart sounds (though physical exam contributes minimally to diagnosing cardiac disease unless shock present) 8, 4
• Respiratory examination: Wheezing, decreased breath sounds unilaterally (pneumothorax) 3

Management Algorithm Based on Risk Stratification

Low-Risk Presentation (No Red Flags Present - 95%+ of Cases)

• Provide reassurance that cardiac causes are extremely rare (1-4%) 1, 2, 3, 7
• Trial of specific therapy based on suspected cause:
  • Musculoskeletal: NSAIDs and activity modification 1
  • Exercise-induced asthma: Inhaled bronchodilator 15-20 minutes before exercise 1
  • GERD: Anti-reflux medication 1
• No routine ECG, chest X-ray, or cardiac referral needed 7, 9
• Arrange follow-up if symptoms persist beyond 2-4 weeks 7

High-Risk Presentation (Red Flags Present)

• Call emergency services immediately - do NOT transport by private vehicle 6, 4, 5
• While awaiting EMS:
  • Place child on cardiac monitor if available 4, 5
  • Obtain vital signs 4
  • Administer aspirin 162-325mg (chewable) if age-appropriate and no contraindications 6, 4
  • Keep child calm and at rest 5
• Emergency department will perform ECG within 10 minutes, cardiac biomarkers, and chest X-ray 8, 4

Critical Pitfalls to Avoid

• Do not dismiss chest pain with syncope as benign - this combination requires cardiac workup to exclude life-threatening arrhythmias 3
• Do not rely on pain severity alone - severity poorly predicts serious disease 8, 4, 5
• In older adolescents with abrupt, continuous pain, obtain chest X-ray carefully - pneumomediastinum can be missed without careful examination 3
• Do not assume normal physical exam excludes cardiac disease - uncomplicated myocardial infarction may present with completely normal examination 8
• Recognize that most chest pain (73.6%) is idiopathic and resolves spontaneously - extensive testing in low-risk patients wastes resources without improving outcomes 3, 7

Special Populations

• Children with sickle cell disease: Chest pain may herald acute chest syndrome (life-threatening) - requires immediate evaluation with chest X-ray, oxygen saturation monitoring, and aggressive pain management 6
• Children with anxiety disorders: 81% of children with unexplained chest pain meet criteria for anxiety disorders - consider mental health referral if organic causes excluded 6
• Athletes with chest pain during exertion: Consider anomalous coronary arteries (second leading cause of sudden cardiac death) - requires cardiology evaluation 6