Chest pain

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Chapter 9 CHEST PAIN

Theodore X. O’Connell

General Discussion

Chest pain in children provokes considerable anxiety for patients and parents. Fortunately, several prospective studies have demonstrated that chest pain in the pediatric age group overwhelmingly is benign. Several organ systems have the potential to cause pain localizing to the thorax. The most common is the musculoskeletal system, where pain can originate from muscle bodies, tendons, ligaments, cartilage, or bone. Other organ systems that can cause chest pain include the respiratory, cardiovascular, gastrointestinal (GI) and nervous systems. Although the differential diagnosis of chest pain is exhaustive, chest pain in children is least likely to be cardiac in origin.

Chest pain is found equally in male and female patients, with an average age of presentation of 13 years. Children younger than 12 years are more likely to have a cardiorespiratory cause of their chest pain compared with children older than 12 years, who are more likely to have a psychogenic cause. Patients diagnosed with psychogenic chest pain or costochondritis are more likely to be female.

All complaints of chest pain should be taken seriously, but chest pain in the pediatric population is rarely associated with life-threatening disease. Chest pain persisting longer than several months is unlikely to be related to serious organic etiology. Pain that is constant or frequently occurring without completely subsiding typically is more worrisome than brief, infrequently occurring episodes of pain.

It may be helpful to understand how the patient and the parents perceive the chest pain. Simply asking the child or adolescent what he or she thinks is causing the pain may help to discover the cause.

Idiopathic is the most frequently encountered diagnosis for chest pain in pediatrics, and the pain is commonly chronic. When the history is unremarkable for serious pathology and the physical examination is normal, further testing generally is not necessary. Several studies have shown that without a specific indication, routine tests were of no benefit in determining the cause of the chest pain.

Causes of Chest Pain

Gastrointestinal

Musculoskeletal

Psychiatric

• Bulimia nervosa

• Hyperventilation syndrome

• Munchausen syndrome

• Panic attacks

• Somotoform disorder

Key Historical Features

Quality of pain

Intensity of pain

Location of pain

Length of time that chest pain has been present

Relationships to exercise, eating, body position, or trauma

Exacerbating and relieving factors

Constitutional symptoms

• Weight loss

• Night sweats

Cardiac symptoms

• Palpitations

• Racing heart

Respiratory symptoms

• Shortness of breath

Gastrointestinal symptoms

Complete review of systems

Past medical history, especially cardiac disease

Past surgical history, especially heart surgery

Family history, especially cardiac disease or sudden death

• Recent stressors at home or at school

• Family dynamics

• Alcohol use

• Tobacco use

• Type of work and play (specific sports activities)

• Change in school performance

Suggested Work-Up

A thorough history and physical examination are usually all that are necessary in excluding the rare, life-threatening causes of chest pain. Laboratory testing is usually nondiagnostic, costly, and burdensome to patients. Laboratory testing is therefore most commonly unnecessary for appropriately diagnosing and treating chest pain in children. The following list is provided only as a guide to the tests that are available in diagnosing chest pain:

Gastrointestinal

Miscellaneous

Musculoskeletal

• Creatine kinase with MM fraction (muscle subunits)

• Computed tomography (CT) scan of spine

• Magnetic resonance imaging (MRI) of spine

• Nuclear bone scan

• Skeletal radiographs

• Bronchoscopy

• Chest radiograph

• CT scan of the chest

• MRI of the chest

• Pulmonary function testing with and without methacholine challenge

• Ventilation perfusion scan

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