Benign chest pain in children

CHEST PAIN is very common in children. Fortunately, serious heart conditions are very rare but include pericarditis, myocarditis, cardiomyopathy, arrhythmias, coronary artery abnormalities, aortic dissection and ingestions. Noncardiac causes of chest pain are seen most frequently and include costochondritis, nonspecific chest wall pain, slipping rib syndrome, trauma or muscle strain. Other noncardiac causes of chest discomfort are attributed to the pulmonary system (pleurisy, asthma, bronchitis); the gastrointestinal system (gastro-esophageal reflux disease, esophageal spasm, ulcer disease or cholecystitis); or psychological issues (anxiety, panic disorder or conversion disorder).

A careful history should focus on the nature of the pain, such as the quality, location, timing, associated factors and activities. The duration of symptoms is very important, as chronic chest pain most likely is not of a cardiac cause. The presence or absence of a past medical history of asthma or pulmonary disease is important. Additionally, history of Kawasaki disease or arterial switch operation for transposition of the great vessels should prompt urgent assessment by a cardiologist. The accompanying chart reviews some common findings and frequently associated conditions.

Physical exam also is important. Patients with abnormal vital signs, such as hypoxemia or resting tachycardia, warrant urgent further assessment. An abnormal cardiac exam, such as friction rub, murmur or gallop, suggests pericarditis, myocarditis or cardiomyopathy. Wheezes, crackles and epigastric tenderness can suggest noncardiac problems. Palpation of the chest wall specifically along the costochondral junctions and eliciting tenderness can suggest musculoskeletal pain. This pain often can be treated with NSAIDs for seven days to reduce inflammation and symptoms.

Reasons to refer to pediatric cardiology include abnormal cardiac findings, exertional chest pain or syncope, associated palpitations, abnormal electrocardiogram, significant family history of arrhythmias or sudden death, history of cardiac surgery or procedures, heart transplant, history of Kawasaki disease, or a first-degree relative with familial hypercholesterolemia.

To make a referral or for medical questions, call (502) 629-2929.

SIGN ASSOCIATED CONDITION
Pinpoint tenderness Chest wall or pleural inflammation
Radiation to neck, throat, jaw, shoulder Ischemia/angina
Radiation to right shoulder Cholecystitis
Radiation to left shoulder Pericarditis
Radiation to interscapular space in back Aortic dissection
Worsen with body movement/breathing Musculoskeletal problem or inflammation of pleura
Aggravated by eating or associated with vomiting Gastrointestinal cause
Precipitated by exertion Cardiac or pulmonary cause
Recent upper respiratory tract infection Pericarditis or myocarditis
Multiple somatic complaints Psychogenic

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