Q&A: Pediatric chest pain
Dorothy Beke, RN, MS, CPNP; Nancy Braudis, RN, MS, CPNP;
and Patricia Lincoln, RN, MS

Beke, Braudis and Lincoln are clinical nurse specialists in Children’s Cardiac ICU

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).

Taking a history of chest pain Medical History When was the onset of pain and when does it occur? Can the child describe the type of pain (e.g., burning, stabbing, sharp)? Does the pain worsen with breathing? Where is the pain located? Is it localized or diffuse? Does the pain radiate anywhere? How long does the pain last? Is the pain related to exercise or activity? Do the child have any other symptoms? Have the child had a recent fever or illness? Has there been any chest wall trauma or recent, stressful life event? Is the pain exaggerated with deep breathing? Family history Has anyone in the family had any known cardiac history? Had anyone in the family had any fainting or abnormal heartbeats? Has anyone in the family had a sudden or early death? Has anyone in the family had any genetic or connective tissue disorder? Has anyone in the family had cardiomyopathy?

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.

	For more information on Children’s Department of Cardiology, visit www.childrenshospital.org/cardiology.