Chest Pain

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Chapter 8 Chest Pain

Steven M. Selbst, MD,FAAP, FACEP

1 How common is chest pain in children?

Chest pain is a common pediatric complaint. It is not nearly as frequent as abdominal pain or headache, but it is perhaps the third leading pain syndrome in children. Chest pain has been reported to occur in 6 of 1000 children who visit an urban pediatric emergency department (ED).

Selbst SM, Ruddy R, Clark BJ, et al: Pediatric chest pain—a prospective study. Pediatrics 82:319–323,1988.

2 What is the peak age for pediatric chest pain?

Most studies report the mean age of children with chest pain to be 12–14 years. It affects children of all ages, and half of children with chest pain are younger than 12 years of age.

3 How does the etiology of chest pain in children differ from that in adults?

Children with chest pain are far less likely to have a cardiac etiology for their pain. Most children with chest pain have a self-limited, “benign” etiology.

Massin MM, Bourguignont A, Coremans C, et al: Chest pain in pediatric patients presenting to an emergency department or to a cardiac clinic. Clin Pediatr 43:231–238, 2004.

4 Which diagnoses are most common in children who present to an ED with chest pain?

In many studies, up to 45% of cases of chest pain in children are labeled “idiopathic.” That is, after a careful history and physical examination, the etiology is still uncertain. When a diagnosis can be found, musculoskeletal injury is most common. Active children frequently strain chest wall muscles while carrying heavy books, exercising, or engaging in rough play. Many other children suffer chest pain from a direct blow to the chest that results in a mild contusion or, in rare cases, a rib fracture. Costochondritis accounts for about 10–20% of cases of chest pain. This musculoskeletal disorder produces tenderness over the costochondral junctions and is often bilateral. It is exaggerated by physical activity or breathing. Musculoskeletal pain is often reproducible by palpation of the chest wall or moving the arms and chest through a variety of positions. Table 8-1 lists the most common etiologies for pediatric chest pain.

Table 8-1 Most Common Causes of Pediatric Chest Pain

Idiopathic Musculoskeletal
  Chest wall strain
  Costochondritis
  Direct trauma
Respiratory conditions
  Asthma
  Cough
  Pneumonia
Gastrointestinal problems
  Esophagitis
  Esophageal foreign body
Psychogenic (stress related)
Cardiac pathology
  Myocarditis

Selbst SM: Chest pain in children—consultation with the specialist. Pediatr Rev 18:169–173, 1997.

5 How is the etiology of chest pain related to the child’s age?

Young children are more likely to have chest pain related to a cardiorespiratory condition (cough, asthma, pneumonia, or heart disease). Children over the age of 12 years are more likely to have a psychogenic disturbance as the cause of their pain.

6 What common gastrointestinal condition causes chest pain?

Gastroesophageal reflux, which is very common in children and accounts for at least 7% of pediatric chest pain. Some feel it is underdiagnosed. The pain is usually worse in the recumbent position. History may reveal that the pain is “burning” in quality and may have developed after eating spicy foods. A trial of antacids is often diagnostic and therapeutic.

KEY POINTS: MOST COMMON CAUSES OF CHILDHOOD CHEST PAIN

1 Musculoskeletal pain

2 Idiopathic cause

3 Pulmonary conditions

4 Psychological cause

5 Trauma

6 Gastrointestinal problems

7 Cardiac disease

8 Sickle cell crises

7 What is Texidor’s twinge?

In 1955, Miller and Texidor described a syndrome of left-sided chest pain that is brief (less than a 5-minute duration) and sporadic. This pain may recur frequently for a few hours in some individuals and then remain absent for several months. The pain seems to be associated with a slouched posture or bending and is not related to exercise. It is usually relieved when the individual takes a few shallow breaths, or sometimes one deep breath, and assumes a straightened posture. It is believed that the pain arises from the parietal pleura or from pressure on an intercostal nerve, but the etiology remains unclear. Others refer to this pain syndrome as “precordial catch” or “stitch in the side.”

Gumbiner CH: Precordial catch syndrome. South Med J 96:38–41, 2003.

8 What is “slipping rib syndrome”?

This is a rare sprain disorder caused by trauma to the costal cartilages of the eighth, ninth and tenth ribs, which do not attach to the sternum. Children with slipping rib syndrome report pain under the ribs or in the upper abdominal quadrants. They also hear a clicking or popping sound when they lift objects, flex the trunk, or even walk. It is believed that the pain is caused by one of the ribs hooking under the rib above and irritating the intercostal nerves. The pain can be duplicated and the syndrome confirmed by performing the “hooking maneuver,” whereby the affected rib margin is grasped and then pulled anteriorly. Intercostal block has been tried for pain relief. Surgery to resect the involved costal cartilage may provide long-term relief, though most patients are treated satisfactorily with oral analgesics.

Mooney DP, Shorter NA: Slipping rib syndrome in childhood. J Pediatr Surg 32:1081–1082, 1997.

9 How can ingestion of tetracycline lead to chest pain?

Tetracycline, doxycycline, and other pill medications can cause acute esophagitis (pill-induced esophagitis). The pain is especially likely if the patient takes the medication with a minimal amount of water and then lies down. A history of esophageal dysmotility or stricture makes the pain more likely. However, many normal teenagers also report this pain. Because of the pH of the drug, doxycycline produces an acidic solution or gel as it dissolves, and thus it is caustic when it remains in the esophagus. Symptoms may be noted several days after the start of therapy with the medication, but frequently they occur after the first dose is taken.

10 How can I diagnose pill-induced esophagitis?

The diagnosis is made by taking a careful history. Physical examination generally is unremarkable. These medications are often taken by adolescents for treatment of acne, and since they are used long-term, teens may fail to reveal that they take the medication unless asked specifically. Some physicians prefer to perform endoscopic evaluation to document esophageal ulcers (midesophageal ulcers are most common, as the tablets are most likely to lodge in that region). Others prefer not to perform the endoscopy and, instead, discontinue use of the tetracycline medications and treat with sucralfate. This approach can be both diagnostic and therapeutic, if the patient responds well.

Palmer KM, Selbst SM, Shaffer S, et al: Pediatric chest pain induced by tetracycline ingestion. Pediatr Emerg Care 15:200–201, 1999.

11 When should a pneumothorax be suspected in a child with chest pain?

Suspect a pneumothorax if a child develops acute onset of sharp chest pain associated with some degree of respiratory distress. The pain is usually worsened by inspiration and may radiate to the shoulder, neck, or even the abdomen. Children with this condition do not have long-standing pain and almost all present for care within 48 hours of developing the pneumothorax. The patient will usually have dyspnea, tachycardia, and, perhaps, decreased breath sounds on the affected side, or even cyanosis. However, these signs and symptoms depend on the size of the pneumothorax and whether it is under tension (Fig. 8-1). A small pneumothorax may produce minimal findings on examination.

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