Chest pain in children

Probability diagnosis

Musculoskeletal (chest wall pain):

• cough strain (10%)

• injury

• muscle strain

• costochondritis

• precordial catch syndrome (stitch in side)

• asthma

Note: Most cases are unknown (21%).

Serious disorders not to be missed

Vascular:

• ischaemic pain: structural cardiac conditions

• arrhythmias (e.g. PSVT)

Infection:

• pericarditis

• myocarditis

• pneumonia

• herpes zoster

Other:

• pneumothorax

• POTS syndrome

Pitfalls (often missed)

Kawasaki syndrome

Breast disorders

Rarities:

• Bornholm disease

• oesophagitis or gastric pain

Is the patient trying to tell me something?

Psychogenic: stress, anxiety, depression (10%).

Key history

• Usual features of the pain including aggravating and relieving factors such as movement, exercise, rest, swallowing, breathing and eating.

• Note associated symptoms such as fever, cough, dizziness, overexertion, syncope and recent viral illness.

• Note family history, especially cardiac disease including unexplained sudden death, recent stressful events and drug history.

Key examination

• Vital signs especially pulse (including nature) and temperature

• Palpation of chest wall to determine any tenderness or signs of injury

• Basic cardiovascular and respiratory examination

Key investigations

• No investigation usually required

• Consider ECG and CXR

Diagnostic tips

• Most cases of chest pain in children are of unknown aetiology and probably psychogenic.

• Chest pain is more common in adolescents.

• Less than 5% of cases are caused by cardiac disease.

• Myocardial ischaemia is rare in children but consider it in any child with exercise-induced pain, adolescents with longstanding diabetes and children with sickle cell anaemia.