What is the evaluation and management approach for chest pain in pediatric patients?

Evaluation and Management of Pediatric Chest Pain

Chest pain in children is rarely cardiac in origin (occurring in only 1-5% of cases), and the evaluation should focus on efficiently ruling out life-threatening causes through targeted history, physical examination, and selective testing rather than extensive cardiac workup. 1, 2, 3, 4

Initial Assessment Priorities

History Taking - Key Red Flags

The following features warrant immediate concern and further cardiac evaluation:

• Exertional chest pain that occurs during physical activity or emotional stress (suggests possible cardiac ischemia) 1, 2
• Syncope or presyncope accompanying the chest pain 1, 2
• Palpitations or sensation of irregular heartbeat 1, 2
• Family history of sudden cardiac death, cardiomyopathy, long QT syndrome, or early coronary artery disease 2, 5
• Sudden onset "ripping" pain radiating to the back (suggests aortic dissection, though rare in pediatrics) 1, 6
• Pain awakening the child from sleep (associated with organic disease) 5
• Fever with chest pain (suggests infectious or inflammatory etiology) 2, 5

Reassuring Features (Suggest Benign Etiology)

• Fleeting pain lasting only seconds (unlikely cardiac) 1, 2
• Sharp, localized pain that can be pointed to with one finger 1, 6
• Positional pain that changes with body position 1, 2
• Reproducible pain with chest wall palpation (though 7% may still have cardiac disease) 7
• Chronic pain lasting more than 6 months without progression 5

Physical Examination - Focused Findings

Cardiovascular Assessment

• Vital signs: Assess heart rate, respiratory rate, blood pressure, and temperature 2
• Cardiac auscultation: Listen for murmurs, abnormal heart sounds (S3 gallop suggests myocarditis), irregular rhythm, or pericardial friction rub 6, 2, 7
• Pulse examination: Check for pulse differentials (suggests aortic dissection) 6

Respiratory Assessment

• Breath sounds: Unilateral decreased or absent breath sounds suggest pneumothorax or pleural effusion 6, 2
• Percussion: Hyperresonance suggests pneumothorax; dullness suggests pneumonia or effusion 6, 2
• Pleural friction rub: Indicates pleural inflammation from pneumonia or pleurisy 6, 2

Musculoskeletal Assessment

• Chest wall palpation: Tenderness of costochondral joints indicates costochondritis (most common identifiable cause at 76% in some series) 2, 3, 8
• Reproducibility: Pain reproduced by palpation strongly suggests musculoskeletal origin but does not completely exclude cardiac causes 7

Diagnostic Testing Algorithm

Mandatory Initial Testing

ECG should be obtained within 10 minutes if any concern for cardiac etiology exists, even if musculoskeletal pain is suspected 1, 2, 7

Indications for ECG:

• Any red flag features listed above 2, 4
• Abnormal cardiac examination 4
• Exertional chest pain 4
• Significant medical or family history 4

When to Obtain Additional Testing

Echocardiography indications:

• Abnormal ECG findings 4
• Abnormal cardiac examination (murmur, abnormal heart sounds) 4
• Exertional syncope or chest pain 4
• Family history of cardiomyopathy or sudden cardiac death 4

Chest radiography indications:

• Respiratory symptoms (cough, dyspnea, tachypnea) 2
• Fever suggesting pneumonia 2
• Concern for pneumothorax or pleural effusion 6, 2

Cardiac troponin measurement:

• Only if acute coronary syndrome is genuinely suspected (extremely rare in children) 2
• Should be measured as soon as possible if ACS is considered 1, 7

Ambulatory ECG monitoring (Holter/event monitor):

• Palpitations with suspected arrhythmia 1
• NOT indicated for isolated chest pain without palpitations (yield <5% in pediatrics) 1

Testing That Can Be Avoided

Exercise stress testing can be eliminated in most cases when using a standardized approach, as it rarely changes management in pediatric chest pain 4

Common Diagnoses and Management

Musculoskeletal Pain (Most Common - 76%)

• Costochondritis: Tenderness at costochondral junctions, reassurance and NSAIDs 2, 3, 8
• Muscle strain: History of trauma or overuse, localized tenderness 8

Respiratory Causes

• Pneumonia: Fever, productive cough, localized findings, treat with appropriate antibiotics 2
• Exercise-induced asthma: Occurs with exertion, wheezing may be present (12% of cases) 3

Gastrointestinal Causes (8%)

• Gastroesophageal reflux: Burning quality, relation to meals 3

Psychogenic Causes (4-21%)

• Anxiety/panic disorder: 81% of children with unexplained chest pain meet criteria for anxiety disorders 2
• Consider referral to cognitive-behavioral therapy if cardiac workup is negative and pain persists 1, 2

Rare Cardiac Causes (1-4%)

• Pericarditis: Sharp, pleuritic pain improved by sitting forward, widespread ST elevation with PR depression on ECG 6, 7
• Myocarditis: Fever, heart failure signs, S3 gallop 6, 7
• Arrhythmias: Palpitations, documented on ECG or monitoring 1, 4

Critical Pitfalls to Avoid

• Do not assume reproducible chest wall tenderness excludes cardiac disease - 7% of patients with reproducible pain still have ACS 7
• Do not use nitroglycerin response as a diagnostic criterion - relief does not confirm or exclude cardiac ischemia 1, 6
• Do not delay transfer for troponin testing in office settings - transport suspected ACS patients urgently to ED by EMS 1, 7
• Do not order extensive cardiac testing without clear indications - this leads to unnecessary cost, radiation exposure, and anxiety 4
• Do not dismiss psychogenic causes - provide thorough explanation, take symptoms seriously, and consider referral when organic causes are excluded 1, 2

Management Approach for Benign Chest Pain

When cardiac and other serious causes are excluded:

• Provide thorough explanation to child and family about the benign nature of the condition 2
• Take symptoms seriously - acknowledge the child's distress 2
• Encourage return to normal activities including school and sports 5
• Consider follow-up until symptoms resolve 2
• Evaluate for underlying anxiety or psychological factors if pain persists despite reassurance 1, 2