Chest Pain in Pediatrics: Diagnosing and Managing Serious Conditions

chest pain in children is a frequent concern for both parents and healthcare professionals. While the first thought may go to heart-related issues, the reality is that chest pain in children is rarely due to a serious cardiac condition. Most cases are benign and resolve without intervention. However, chest pain can sometimes signal an underlying problem that requires medical attention.

This article will explore the common causes of chest pain in children, the red flags to watch out for, and the diagnostic approaches and management strategies healthcare professionals should employ. It also includes practical guidelines for physicians to help parents understand when they should be concerned and seek medical help.

Understanding the Basics: Is chest pain in Children Dangerous?

Unlike adults, where chest pain is often a hallmark symptom of cardiovascular disease, in children, it is seldom related to the heart. Only 1% to 5% of pediatric chest pain cases are cardiac in origin, and the vast majority stem from musculoskeletal, pulmonary, or gastrointestinal causes. Still, chest pain in a child can be distressing, and it is crucial for physicians to be able to differentiate between benign and concerning cases.

Non-Cardiac Causes of chest pain in Children

1. Musculoskeletal Causes
   • Costochondritis: This is the most common cause of chest pain in children. It involves inflammation of the cartilage that connects the ribs to the sternum and typically presents as sharp, localized pain that worsens with movement or deep breathing.
   • Muscle strain: Physical activities, especially those involving the upper body, such as sports, can lead to muscle strain in the chest or rib muscles. This type of pain is also localized and worsens with certain movements.
   • Precordial Catch Syndrome: Another common cause of chest pain, often mistaken for something more serious. It presents as a sharp, stabbing pain typically on the left side of the chest. The pain lasts for a few seconds to a few minutes and resolves on its own.
2. Pulmonary Causes
   • Asthma: Although asthma typically manifests with wheezing and shortness of breath, some children may report chest pain during asthma attacks or prolonged coughing episodes. The pain is usually relieved by bronchodilator therapy.
   • Pneumonia or Bronchitis: Infection of the lungs or bronchi can cause chest pain, particularly if there is an associated cough or fever. In these cases, chest pain often accompanies symptoms like productive cough, fever, and fatigue.
   • Spontaneous Pneumothorax: This is a rare but important consideration, particularly in adolescents. It presents with sudden-onset sharp chest pain and shortness of breath. In some cases, this can be life-threatening and requires immediate attention.
3. Gastrointestinal Causes
   • Gastroesophageal Reflux Disease (GERD): Acid reflux can lead to heartburn or a burning sensation in the chest, often mistaken for cardiac pain. The pain usually follows meals and is relieved by antacids.
   • Esophagitis: Inflammation of the esophagus can result in chest pain, typically presenting with a burning or squeezing sensation that may mimic heart pain.
   • Esophageal Spasms: Rare in children, esophageal spasms can cause severe, non-cardiac chest pain and difficulty swallowing.

Cardiac Causes of chest pain in Children

Though rare, cardiac causes of chest pain in children must be taken seriously. Some potential cardiac causes include:

1. Congenital heart disease: Conditions such as aortic stenosis or pulmonary hypertension can occasionally cause chest pain in children, especially during exertion. These children may also exhibit symptoms like shortness of breath, cyanosis, or a history of fainting.
2. Pericarditis: Inflammation of the pericardium, the sac surrounding the heart, can cause sharp chest pain, often worsening when lying down and improving when leaning forward. A pericardial friction rub may be audible on auscultation.
3. Arrhythmias: Some arrhythmias, such as supraventricular tachycardia (SVT), can cause chest pain, especially if they result in decreased cardiac output. Symptoms like palpitations, dizziness, or syncope often accompany the chest pain.
4. Myocarditis: Viral infections can lead to myocarditis, or inflammation of the heart muscle. Children may present with chest pain, fatigue, fever, and sometimes heart failure symptoms. This condition can be serious and requires prompt medical attention.
5. Coronary Artery Abnormalities: While exceedingly rare, coronary artery abnormalities can cause chest pain in children. These cases are typically triggered by exertion and may be associated with a family history of sudden cardiac death.

Red Flags: When to Worry About chest pain in Children

Most pediatric chest pain is benign, but there are certain signs and symptoms that warrant closer attention. Here are some red flags that physicians should be aware of:

• chest pain with exertion: Any child experiencing chest pain during or immediately after physical activity should be evaluated for potential cardiac causes.
• Syncope or near-syncope: chest pain associated with fainting or lightheadedness raises the possibility of a serious arrhythmia or structural heart disease.
• Radiating pain: Pain that radiates to the jaw, left arm, or back can be suggestive of cardiac ischemia, although extremely rare in children.
• Associated systemic symptoms: Fever, weight loss, fatigue, and night sweats may indicate an underlying infection, such as myocarditis or pericarditis, or other serious systemic illnesses.
• Family history of sudden cardiac death: A family history of sudden death, cardiomyopathy, or arrhythmias increases the suspicion for a genetic cardiac condition.
• Abnormal physical exam findings: Murmurs, gallops, rubs, or other abnormal heart sounds should prompt further investigation.

Diagnosing chest pain in Children: A Stepwise Approach

1. History and Physical Examination

A thorough history and physical examination are the cornerstones of diagnosis in pediatric chest pain. Key elements to explore include:

• Onset and duration: Was the pain sudden or gradual? How long did it last?
• Pain characteristics: Is it sharp, dull, or burning? Is it constant or intermittent?
• Location: Is the pain localized or diffuse? Does it radiate anywhere?
• Triggers: Does it occur during exercise, after meals, or at rest?
• Associated symptoms: Ask about shortness of breath, palpitations, dizziness, fever, or cough.
• Past medical history: Explore any history of asthma, recent infections, or trauma.
• Family history: Inquire about any cardiac disease or sudden death in the family.

2. Physical Examination

A focused physical examination should include:

• Cardiovascular exam: Auscultate for murmurs, rubs, or extra heart sounds. Palpate for thrills or heaves. Assess pulses in all extremities.
• Respiratory exam: Listen for wheezes, crackles, or decreased breath sounds. Inspect for signs of respiratory distress.
• Musculoskeletal exam: Palpate the chest wall, especially over the costosternal junctions, to reproduce pain. Assess range of motion in the shoulders and upper chest.

3. Diagnostic Testing

The need for diagnostic testing will depend on the findings from the history and physical examination. In cases where the chest pain is clearly musculoskeletal or related to an upper respiratory infection, testing may not be necessary. However, in other cases, the following tests might be useful:

• Electrocardiogram (ECG): This is an essential tool to rule out arrhythmias, myocarditis, or ischemia. Any child with concerning symptoms should undergo an ECG.
• Chest X-ray: A chest X-ray can help diagnose pneumonia, pneumothorax, or rib fractures. It also gives insight into cardiac size and pulmonary vasculature.
• Echocardiogram: If a cardiac cause is suspected, an echocardiogram will provide detailed information about heart function, valvular abnormalities, or pericardial effusion.
• Pulmonary function tests: In children with suspected asthma or other pulmonary conditions, pulmonary function tests may be helpful.
• Blood tests: In rare cases of suspected myocarditis or pericarditis, laboratory tests such as troponin levels or inflammatory markers (e.g., ESR, CRP) may be indicated.

Management of chest pain in Children

The treatment of pediatric chest pain depends on the underlying cause:

1. Musculoskeletal causes: Rest, anti-inflammatory medications (such as ibuprofen), and physical therapy are typically sufficient to manage musculoskeletal chest pain. Costochondritis often resolves with time, but persistent cases may benefit from heat or ice therapy.
2. Pulmonary causes: Asthma should be treated with bronchodilators and, if necessary, inhaled corticosteroids. In cases of pneumonia, antibiotics are indicated, while spontaneous pneumothorax may require chest tube insertion.
3. Gastrointestinal causes: GERD can be treated with lifestyle modifications and acid suppression therapy, such as proton pump inhibitors (PPIs) or H2 blockers. Severe cases of esophagitis may require additional medications.
4. Cardiac causes: Cardiac conditions require referral to a pediatric cardiologist. Depending on the diagnosis, treatment may range from medication management for arrhythmias or myocarditis to surgical intervention for structural abnormalities.

Educating Parents: When to Seek Medical Help

Parents often need reassurance when their child experiences chest pain. Educating them on the common, benign causes of chest pain can alleviate anxiety. However, it's equally important to inform them of the red flags:

• chest pain that occurs with exertion or physical activity
• Pain accompanied by dizziness, fainting, or shortness of breath
• A family history of cardiac disease or sudden death
• Any abnormal findings during a physical exam or ongoing symptoms that do not resolve

By empowering parents with knowledge, physicians can reduce unnecessary emergency room visits while ensuring that concerning cases receive timely attention.

Conclusion

chest pain in children is usually benign, with the majority of cases arising from musculoskeletal, respiratory, or gastrointestinal causes. However, a small subset of children may have serious underlying conditions, particularly cardiac or pulmonary in origin. A detailed history, thorough physical examination, and appropriate use of diagnostic tools are essential for distinguishing between benign and concerning cases. Healthcare professionals should educate parents on the common causes of chest pain in children and the warning signs that require further evaluation.