CHAPTER 141 Chest Pain

ETIOLOGY

Chest pain in the pediatric patient often generates a significant amount of patient and parental concern. Although chest pain is rarely cardiac in origin in children, common knowledge about atherosclerotic heart disease raises concerns about a child experiencing chest pain. Most diagnosable chest pain in childhood is musculoskeletal in origin. A significant amount remains idiopathic; however. Knowledge of the complete differential diagnosis is necessary to make an accurate assessment (Table 141-1).

TABLE 141-1 Differential Diagnosis of Pediatric Chest Pain

COMMON

Musculoskeletal

Costochondritis

Trauma or muscle overuse/strain

Pulmonary

Asthma (often exercise-induced)

Severe cough

Pneumonia

Gastrointestinal

Reflux esophagitis

Psychogenic

Anxiety, hyperventilation

Miscellaneous

Precordial catch syndrome (Texidor’s twinge)

Sickle cell vaso-occlusive crisis

Idiopathic

UNCOMMON/RARE

Cardiac

Ischemia (coronary artery abnormalities, severe AS or PS, HOCM, cocaine)

Infection/inflammation (myocarditis, pericarditis, Kawasaki disease)

Dysrhythmia

Mitral valve prolapse

Musculoskeletal

Abnormalities of rib cage/thoracic spine

Tietze syndrome

Slipping rib

Tumor

Pulmonary

Pleurisy

Pneumothorax, pneumomediastinum

Pleural effusion

Pulmonary embolism

Gastrointestinal

Esophageal foreign body

Esophageal spasm

Psychogenic

Conversion symptoms

Somatization disorders

Depression

AS, aortic stenosis; HOCM, hypertrophic obstructive cardiomyopathy; PS, pulmonary stenosis.

CLINICAL MANIFESTATIONS

Assessment of a patient with chest pain includes a thorough history to determine activity at the onset; the location, radiation, quality, and duration of the pain; what makes the pain better and worse during the time that it is present; and any associated symptoms. A family history and assessment of how much anxiety the symptom is causing are important and often revealing. Although the history alone often determines the etiology, a careful general physical examination should focus on the chest wall, heart, lungs, and abdomen. A history of chest pain associated with exertion, syncope, or palpitations, or acute onset associated with fever suggests a cardiac etiology. Cardiac causes of chest pain are generally ischemic, inflammatory, or arrhythmic in origin.

DIAGNOSTIC STUDIES

Tests rarely are indicated based on the history. A chest x-ray, electrocardiogram (ECG), 24-hour Holter monitoring, echocardiogram, and exercise stress testing may be obtained based on history and examination. Referral to a pediatric cardiologist is based on the history, physical examination findings, family history, and frequently the level of anxiety in the patient or family members regarding the pain.