Symptom-Based Diagnosis in Pediatrics (CHOP Morning Report) 1st Ed.

CHAPTER 14. CHEST PAIN

DEBRA BOYER

LIANNE KOPEL

DEFINITION OF THE COMPLAINT

Chest pain is a relatively common complaint in children with a frequency of 0.6% of pediatric emergency room visits. It occurs equally in boys and girls with a median age at presentation of 12 years. The most common causes of chest pain in children are generally benign but this complaint causes much anxiety among parents and patients due to concern for a cardiac etiology (Table 14-1).

TABLE 14-1. Common causes of chest pain in children.

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In understanding the multiple causes for chest pain, one must consider the various innervation patterns that occur throughout the chest. Musculoskeletal pain is transmitted via intercostal nerves while the vagus nerve innervates the large bronchi and trachea. Pain fibers from the parietal pleura travel via intercostal nerves while the visceral pleura lacks pain fibers. Peripheral diaphragmatic disease is transmitted through intercostal fibers, and therefore can cause referred pain in the chest wall. This is in contrast to the central diaphragm, innervated by the phrenic nerve, which results in pain referred to the shoulder. The pericardium has multiple innervations including the phrenic, vagal, and recurrent laryngeal nerves, as well as the esophageal plexus. Thus, pericardial disease can present with diverse sensations and can be difficult to diagnose. Finally, cardiac pain itself transmits via the thoracic sympathetic chain and other cardiac nerves. Chest pain, therefore, is a very general term that can describe a variety of symptoms and etiologies. Only by a very careful history and physical examination can one accurately determine the cause of the patient’s discomfort.

COMPLAINT BY CAUSE AND FREQUENCY

Causes of chest pain in children can be separated by age (Table 14-2) or etiology (Table 14-3). Chest pain is classified as idiopathic in 20%-61% of cases. In terms of organic etiology, 7%-69% of cases are determined to be musculoskeletal, 13%-24% of cases are respiratory (including asthma), less than 10% of cases are psychogenic and gastrointestinal in origin, and cardiac causes are found in 5% of cases or less. Children younger than 12 years of age are more likely to have a cardiac or respiratory etiology, whereas children older than 12 years of age will more often have psychogenic causes for their chest pain. In one study, most children presented with pain duration of less than 24 hours. However, children with a nonorganic cause are more likely to have pain lasting over 6 months.

TABLE 14-2. Causes of chest pain in childhood by age.

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TABLE 14-3. Causes of chest pain in childhood by etiology.

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CLARIFYING QUESTIONS

A complete history and physical examination will often reveal the diagnosis in a patient with chest pain. It is essential to have the patient describe the pain in detail: time of onset, duration, frequency, intensity, location, radiation, precipitating, and relieving factors. The patient’s activity at the time of diagnosis can often provide valuable information. The following questions may provide clues to the diagnosis:

• Is the chest pain associated with exertion, syncope, or palpitations?

—Chest pain associated with exertion, syncope, or palpitations is more concerning for cardiopulmonary disease and warrants further investigation. Chest pain with exertion may indicate exercise-induced asthma. Hypertrophic cardiomyopathy and aortic stenosis should always be considered in children presenting with chest pain on exertion. In children with anomalous coronary arteries, there may be insufficient coronary blood flow during exercise, causing symptoms to manifest at this time. In some cases, syncope may also occur. Palpitations may indicate an underlying arrhythmia such as supraventricular tachycardia or ventricular tachycardia.

• How is the pain characterized?

—Pain that is worse on inspiration or coughing but is poorly localized may indicate pleural or pulmonary pathology, whereas similar pain that is well localized and elicited on palpation is usually related to a chest wall etiology. Cardiac pain may be described as squeezing or pressure-like in quality, and may radiate to the left arm or neck. Midsternal pain may come from the esophagus, particularly if it worsens when supine. Kehr sign, or acute pain felt in the shoulder, may represent blood in the peritoneal cavity. Finally, psychogenic pain may be nonspecific in location and vague in quality.

• Is there a family history of sudden death?

—Hypertrophic cardiomyopathy is inherited in an autosomal dominant fashion, so there may be a family history of sudden death. These patients may have a murmur that is augmented with standing or a Valsalva maneuver. Furthermore, their chest pain may be most severe with exercise. In congenital hyperlipidemia, patients may present at a young age with myocardial infarction and have a family history of sudden death.

• Is the pain relieved with changes in position?

—Patients with pericarditis often have stabbing precordial pain that worsens while lying down and improves with sitting and leaning forward. These patients are often febrile, have a friction rub that is best heard while the patient leans forward, and may also have distant heart sounds, jugular venous distension, and pulsus paradoxus.

• Is there a history of precipitating trauma?

—In the trauma patient, tachycardia and hypotension may be secondary to a hemothorax or other vascular injury. In patients with poor perfusion and decreased cardiac output, one should consider myocardial contusion, tension pneumothorax, and cardiac tamponade.

• Is there a prior history of cardiorespiratory disease?

—Patients with a history of asthma, cystic fibrosis, and connective tissue disorders have an increased risk of pneumothorax and pneumomediastinum.

• Can the pain be reproduced on physical examination?

—Musculoskeletal pain generally can be elicited by palpation of the chest wall. Costochondritis, most commonly seen in teenage girls, is associated with palpable pain over the costal cartilage. Muscle strain, which may result from cough or new/vigorous physical activity, will generally have palpable pain over the affected muscle.

• Does the child have fever?

—Fever is a nonspecific sign that may be present with pneumonia, pericarditis, myocarditis, endocarditis, or pleurodynia (most often caused by infection with coxsackievirus B).

• Is the child taking any medications?

—Oral contraceptives increase the risk of pulmonary embolism. Steroids and nonsteroidal antiinflammatory medications increase the risk for gastritis. Iron, tetracyclines, and nonsteroidal antiinflammatory agents among others may cause pill esophagitis.

• Does the pain relate to meals?

—Chest pain from gastroesophageal reflux commonly occurs after meals.

• Have there been any recent stressors in the patient’s life?

—Psychogenic chest pain may occur in patients with recent major stressful events in their lives. These patients often have multiple somatic complaints in addition to chest pain. A family history of depression or a somatization disorder increases the likelihood that a child will develop psychogenic pain.

• Does the pain wake the child from sleep?

—Children who awake from sleep secondary to chest pain are more likely to have an organic etiology.

• Is there a history of substance use or abuse?

—Tobacco use may be associated with a chronic cough and chest pain. Cocaine and methamphetamine abuse may lead to coronary artery vaso-spasm and ischemic chest pain.

SUGGESTED READINGS

1. Byer RL. Pain-chest. In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 6th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010:434-442.

2. Thull-Freedman J. Evaluation of chest pain in the pediatric patient. Med Clin North Am. 2010;94(2):327-347.

3. Tunnessen WW. Chest pain. In: Tunnessen WW, Roberts KB, eds. Signs and Symptoms in Pediatrics. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 1999:361-369.

4. Kocis KC. Chest pain in pediatrics. Pediatr Clin North Am. 1999;46(2):189-203.

5. Lin CH, Lin WC, Ho YJ, Chang JS. Children with chest pain visiting the emergency department. Pediatr Neonatol. 2008;49(2):26-29.