Paediatric Chest Pain

Most of the time, chest pain in children originates from a benign cause. However, paediatric chest pain can be a sign of serious pathology, particularly cardiac. It is important that, as the clinicians who often clerk children when they first present to hospital, FY1 doctors are able to recognise the features that would make chest pain in a child concerning. Equally, it is important to acknowledge patients’ and parents’/caregivers’ concerns about chest pain of a benign cause (it can be scary!) and offer reassurance and advice where appropriate.

Aetiology

Non-Cardiac (Common)Cardiac (Rare)
Costochondritis – Chest wall tendernessPericarditis – Worse on lying down
Injury – History of traumaMyocarditis – Chest pain with breathlessness
Stress or anxiety – Psychological prodrome e.g signs of bullying, worsening school performance, parental concern, specific worries preceding the painCoronary artery abnormalities – History of Kawasaki disease
Precordial catch syndrome – Sudden, sharp/stabbing pain on left side of chest – self-terminates in secondsAortic dissection or rupture – History of connective tissue disorder, pain radiating to back
Acid reflux – Relationship with meal timesArrhythmia – Concurrent palpitations
Bronchospasm – History of asthma and/or wheeze on auscultationLeft ventricular outflow tract obstruction – Shortness of breath, family history
Causes of paediatric chest pain characterised into cardiac and non-cardiac with features that would be suggestive of each cause.

History

A thorough history is key to differentiating between concerning and benign causes of chest pain. An older child or adolescent may be able to answer your questions, while an infant will likely rely on a parent/caregiver to communicate on their behalf. While the core of your history should include the SOCRATES framework, there are some specific questions which can guide diagnosis. Some reassuring features are:

• Pain worse on movement – Likely musculoskeletal
• Pain worse after eating – Likely gastrointestinal reflux
• Recent stressors, stressful life event or history of anxiety
• Short-lived pain lasting a few seconds

Figure 1 includes red flag symptoms which should be screened for in all children presenting with chest pain. Further investigation and referral to paediatric cardiology is indicated if any of these features are present.

Picture1
Figure 1: Red flags for chest pain in children

Children with chest pain originating from a concerning cause will often have relevant past medical history such as:

  • The detection of a congenital abnormality during antenatal scans or postnatal checks
  • A history of cardiac surgery or
  • A history of Kawasaki disease or connective tissue disorder e.g Marfan syndrome or vascular Ehlers-Danlos syndrome

These children will likely already be subject to consultant follow-up and may have previous clinic letters in their notes that you can refer back to.

A comprehensive family history can also aid the detection of a serious cause of chest pain in children since cardiomyopathies, channelopathies and other pathologies which cause sudden cardiac death have a high degree of heritability.

Since anxiety is such a common cause of chest pain in children, particularly in adolescents, a HEEADSSS (Home, Education, Eating, Activities, Drugs, Sexuality, Suicide, Safety) assessment is indicated. It is therefore important to build a good rapport with these patients so that they feel that they can share any worries with you.

Examination

A full head-to-toe examination is advised when clerking any patient, particularly children. This should include auscultation of the heart and chest and palpation of the abdomen. There are, however, some particular tests and manoeuvres that can be used to aid the diagnosis of chest pain in children.

  • Pain on palpation of the chest wall → Likely musculoskeletal
  • Worse on laying down → Concerning for pericarditis (though if after eating, may be acid reflux)
  • Chest pain with breathlessness, worse on sitting forward → Concerning for myocarditis

Investigations

In the hospital setting, patients often come accompanied by an observations chart (in primary care, these observations should be performed by you). A normal set of observations is reassuring and suggests there is no acute cardiovascular compromise. However, this does not negate the need for a thorough history and examination as described above.

Careful consideration should be given to whether or not to obtain blood tests in paediatric patients. Children often find having blood taken particularly unpleasant and therefore if blood testing is required it should be clear how the result will alter the child’s management. There should be a high suspicion of myocardial injury if a troponin measurement is requested, for example.

Most children with chest pain will have an ECG but this is only necessary if the history and examination are suggestive of a cardiac cause or if there is a component of the past medical or family history that causes concern for cardiac pathology.

Management

Musculoskeletal chest pain can often be treated with non-steroidal anti-inflammatory drugs such as ibuprofen or paracetamol. Acid reflux that is causing pain can be treated with a 4-week trial of a proton pump inhibitor such as omeprazole or lansoprazole or an H2 receptor antagonist such as oral ranitidine.

Reassurance is often a significant part of the management plan for children with chest pain of a benign cause. However, appropriate safety netting advice should be provided, and children and their parents/caregivers should be aware that they can present again if they are concerned. In addition, signposting to relevant services should take place such as to physiotherapy for musculoskeletal chest pain and mental health services if chest pain is related to anxiety – While ruling out a cardiac pathology is important, so is helping children manage benign chest pain.

If an FY1 doctor is not satisfied that a child’s chest pain is of a non-worrying cause, or the child displays one or more of the red flag features outlined in figure 1, they should involve their seniors who may wish to consider referring on to a specialist.

A child who is found to have chest pain of a cardiac cause will likely be managed by a specialist. Interventions may include beta-blockers, anti-arrhythmic drugs, implantable cardiac defibrillator implantation or surgical intervention.

Resources & References

  1. Huxstep, Miller and Brooke. Chest Pain in Children: When to Worry, When to Refer.
  2. Collins, Griksaitis and Legg (2014). 15-minute consultation: A structured approach to the assessment of chest pain in a child.
  3. NICE CKS

Written by Shôn Alun Thomas, Year 4 Medical Student, Cardiff University School of Medicine
Reviewed by Dr Dirk Wilson, Paediatric Cardiologist
Edited by Dr James Mackintosh, Paediatric Lead, Mind The Bleep

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