Q&A: Pediatric
chest pain
Dorothy Beke, RN, MS, CPNP; Nancy Braudis, RN, MS, CPNP;
and Patricia Lincoln, RN, MS
How often is pediatric chest pain related to cardiac
disease?
Chest pain is a common complaint in the pediatric population,
and results in many visits to pediatricians and emergency rooms,
as well as a great number of referrals to pediatric cardiologists.
Although a child’s chest pain is understandably frightening for
parents, unlike in adults, this symptom in children is rarely
life threatening or cardiac in nature. Studies have shown children’s
chest pain to be associated with cardiac disease in just one to
four percent of cases.
What are the likely causes of chest pain in a pediatric
patient?
The etiology of chest pain is most often unknown. Data show that
typically, musculoskeletal chest pain is described as originating
in the area between the lungs, is sharp, brief in duration and
increases with respirations. This type of chest pain is not generally
associated with physical activity, and the pain may be reproduced
with palpation of the chest wall, indicating muscle strain or
costochondritis (inflammation of the cartilage between the ribs).
What are other possible diagnoses?
Other common sources of chest pain in children include problems
in the musculoskeletal and respiratory systems. Psychogenic, gastrointestinal
and other causes of chest pain are less frequently identified.
Studies have shown that organic causes are usually related to
pain that wakes a child from sleep, has an acute onset, corresponds
to abnormal physical findings or occurs when fever is present.
Non-organic causes were related to chronic chest pain (lasting
longer than six months) or to a family history of heart disease
or chest pain. Here is a comprehensive list of diagnoses, from
most to least common:
1 Idiopathic origin
2 Musculoskeletal
3 Cough
4 Costochrondritis
5 Asthma
6 Trauma
7 Pneumonia
8 Psychogenic origin
9 Gastrointestinal
disorders
10 Cardiac disease
Anatomic lesions
Acquired lesions
Arrhythmias
11 Sickle
cell crisis
12 Ingestion
13 Breast disease
14 Mediastinal
tumors
15 Other
What is the best way to diagnose the cause of pediatric
chest pain?
A thorough history and physical exam are essential to the assessment
and accurate diagnosis of chest pain and development of a treatment
plan. The history must include precipitating events and the descriptive
experience of pain during and after the period of discomfort.
Onset of pain, location, duration, characteristics, aggravating
factors, alleviating factors and any treatment are crucial elements
of the history. The current and past medical history should include
medications and illnesses, which may contribute to symptoms of
chest pain. Family history of cardiac disease or sudden death,
social history including recreational substance use, history of
physical activity and a review of systems are important components
of the patient interview.
A complete physical examination is equally necessary to a good
history. Palpation of the chest wall structures, including the
bones and musculature, and palpation of the abdomen can help rule
out abnormalities. Chest wall tenderness may often be elicited
during the exam, and may help to exclude cardiac etiology. A cardiac
examination should focus on palpation of cardiac impulse, differentiation
of pediatric heart sounds, presence of murmur, click or rub, detection
of potential rhythm disturbances, and quality of pulses and distal
perfusion.
What patients should be referred to a pediatric cardiologist?
Although pediatric chest pain is often benign, a systematic approach
to assessing chest pain will enable the health care provider to
identify patients who require further evaluation by a specialist.
Refer the patient to a pediatric cardiologist if chest pain is
associated with:
-
Physical exertion
- Palpitations, dizziness and/or syncope
-
Rhythm disturbances
-
History of previous cardiac surgery
- Family history of sudden death and/or hypertrophic cardiomyopathy
- History of Kawasaki
disease
-
History of connective tissue disorders (e.g.,
Marfan syndrome)
- History of aortic
stenosis
Keep in mind that
some patients who do not require specialist care may nevertheless
experience chronic pain requiring long-term care.
Reassurance
and explanations of the many possible causes of pediatric chest
pain are necessary to developing a therapeutic relationship and
alleviating family apprehension.
