What is the appropriate evaluation and management of sternal chest pain in a child?

Evaluation and Management of Sternal Chest Pain in Children

Initial Assessment Priority

In children presenting with sternal chest pain, immediately assess for life-threatening conditions through focused history, physical examination, and ECG, recognizing that cardiac causes are rare (1-4% of cases) but must be excluded before providing reassurance. 1, 2, 3, 4

Immediate Life-Threatening Conditions to Exclude

While uncommon in children, the following require urgent identification:

• Cardiac emergencies: Pericarditis (sharp, pleuritic pain worse when supine, improved leaning forward, with friction rub), myocarditis (chest pain with fever, signs of heart failure), or arrhythmias 1, 5
• Pulmonary embolism: Acute dyspnea with pleuritic chest pain, tachycardia, and tachypnea 6, 5
• Pneumothorax: Dyspnea and pain on inspiration with unilateral absent breath sounds 1, 5
• Acute aortic syndromes: Sudden-onset "ripping" or "tearing" pain with radiation to back (extremely rare in children) 6, 5

Critical History Elements

Obtain specific details about:

• Pain characteristics: Exact location on sternum, quality (sharp, pressure, stabbing), onset (sudden vs. gradual), duration, and severity 7, 6, 1
• Radiation pattern: To arms, jaw, neck, or back 7, 6
• Precipitating factors: Exertion, stress, breathing (pleuritic), position changes, or meals 7, 6, 1
• Associated symptoms: Fever (suggests infection), dyspnea, cough (respiratory cause), diaphoresis, nausea, syncope, or palpitations 7, 6, 1
• Temporal features: Fleeting pain lasting only seconds is unlikely cardiac 7, 5

Focused Physical Examination

Systematically evaluate:

• Vital signs: Temperature, heart rate, respiratory rate, blood pressure 1
• Respiratory system: Abnormal breath sounds, decreased breath sounds unilaterally, friction rub 1
• Cardiovascular system: Murmurs, S3 gallop, friction rub, irregular rhythm, pulse differentials 1, 5
• Musculoskeletal system: Chest wall tenderness, reproducible pain with palpation of costochondral joints (costochondritis) 1, 5
• Skin: Dermatomal distribution suggesting herpes zoster 1

Diagnostic Testing Algorithm

ECG is NOT routinely required in children with chest pain unless specific red flags are present (unlike adult guidelines). 2, 8, 9, 4

Indications for ECG:

• Exertional chest pain 4
• Abnormal cardiac examination findings 4
• Clinically significant medical or family history (premature sudden cardiac death, cardiomyopathy, arrhythmias) 4
• Severe respiratory distress or signs of cardiac compromise 1
• Syncope or presyncope with chest pain 6

Additional Testing Based on ECG and Clinical Findings:

• Echocardiography: Only if abnormal ECG, abnormal cardiac examination, or significant family history 4
• Exercise stress testing: Generally not indicated; the algorithm application could eliminate this testing 4
• Chest radiograph: If respiratory symptoms (cough, dyspnea, fever) suggest pneumonia or pneumothorax 7, 1
• Cardiac troponin: Only if acute coronary syndrome suspected (extremely rare in children) 7, 6

Common Benign Etiologies in Children

The vast majority of pediatric chest pain is benign:

• Idiopathic chest pain: 21-59% of cases 3
• Musculoskeletal (costochondritis): 7-16% of cases, characterized by reproducible tenderness at costochondral joints 1, 3
• Pulmonary causes: 12-24% of cases, including exercise-induced asthma 3
• Psychologic/anxiety disorders: 17-19% of cases; 81% of children with unexplained chest pain met criteria for anxiety disorders in one study 7
• Gastrointestinal (GERD): 5-7% of cases 3
• Cardiac causes: Only 1-4% of cases 3, 4

Management Approach

For Benign Causes:

• Costochondritis: NSAIDs for musculoskeletal pain 3
• Exercise-induced asthma: Trial of inhaled bronchodilator 15-20 minutes before exercise 3
• GERD: Adequate anti-reflux medication 3
• Anxiety-related: Consider mental health referral; 81% of children with unexplained chest pain had anxiety disorders 7

Reassurance Strategy:

• Provide thorough explanation that symptoms are being taken seriously 7
• Explain benign nature when organic cause excluded 3
• Follow until symptoms resolve 1
• Consider underlying diagnoses (immunodeficiency, congenital anomalies) if recurrent or persistent 1

Critical Pitfalls to Avoid

• Do not assume young age excludes serious pathology: While rare, life-threatening conditions can occur 6
• Do not rely on nitroglycerin response: Esophageal spasm and other non-cardiac conditions also respond 6, 5
• Do not dismiss sharp or pleuritic pain: Pericarditis presents this way 7, 5
• Avoid extensive unnecessary testing: Only 1.2% of pediatric cardiology referrals for chest pain had cardiac etiology; targeted testing based on history, examination, and ECG findings can reduce echocardiogram use by 20% and eliminate stress testing while capturing all cardiac diagnoses 4
• Do not overlook psychological causes: Somatic symptom disorders are common and require mental health evaluation 7