Chest Pain in Children: ReBaked Morsel

Children like to pretend to be grown-ups.  Unfortunately, sometimes they develop grown-up problems (Cholelithiasis, Kidney Stones, and Hypertension).  Additionally, often kids will complain of symptoms that warrant great concern in adults, but often engender apathy when considered in children. Chest Pain in Children is a great example of one of these complaints.

Chest Pain in Children: Hysteria vs Vigilance

• Diverse pathology can present as chest pain in children
  • Cardiac 1-9% 
  • GI 2-10% 
  • Musculoskeletal – 2-20% 
  • No Identifiable cause – 21-45% of the time!
• Yet, our job requires vigilance to find the needle in the haystack

Chest Pain in Children: Thorough History Matters 

• Remember teen are more forthcoming privately
  • If we don’t ask, we won’t know!!!
    • Ask about suicidal ideation: Let’s not miss a caustic ingestion…
    • Ask about birth control: Teens may be on OCPs and at increased risk for PE and their parents don’t know it
    • Ask about drugs: Does your patient smoke, vape, or use cocaine?
• Add the risk assessment for sudden cardiac death into your workflow
  • Have you ever fainted or had a seizure without warning, during exercise or in response to a loud noise?
  • Have you ever had chest pain or shortness of breath in exercise?
  • Has anyone in the family died unexpectedly before age 50?
  • Is there a family history of sudden death, hypertrophic cardiomyopathy, long QT syndrome, or tachyarrhythmias?

Chest Pain in Children: Culprits to Consider

• Cardiac
  • Hypertrophic Cardiomyopathy
    • EKG abnormal in 95% of cases
    • Left Axis Deviation
    • Large Voltages
    • Deep, narrow Q waves in lateral leads
    • Deep, narrow T wave inversions in lateral leads
  • Tachyarrhythmias
    • Look specifically for:
      • Prolonged QTc, Short PR, delta waves, evidence of HOCM, ST Elevations, symmetric TWI, AV Blocks, Brugada Sign.
  • Pericarditis
  • Myocarditis
  • Ischemia
    • Though rare, it can happen!! Think ALPACA and Kawasaki
• Pulmonary
  • Pneumothorax
  • Pneumomediastinum
  • Asthma
  • Pneumonia
  • Lung Abscess
  • Pulmonary Embolism (PE)
    • Especially if your patient is obesity and on OCPs
  • Aspirated Foreign Body
• Heme
  • Acute Chest syndrome
    • In patients with Sickle Cell Disease
• Rheumatologic
  • Pulmonary hemorrhage
    • In patients Lupus and other types of vasculitis 
• Vascular
  • Aortic Dissection
• Chest Wall
  • Herpes Zoster
  • Trauma
  • Costochondritis
• GI
  • GERD
  • Esophagitis from EOE or given just one doxycycline pill
  • Caustic & Foreign Body Ingestion 

Chest Pain in Children: Physical Exam

Look for clues on your patient’s physical exam to guide your work-up!

• Cardiac
  • Murmurs, gallops or rubs?
  • Equal pulses?
  • Is there peripheral edema? Is it symmetric? 
  • How is our perfusion? 
• Pulmonology
  • Listen for locality in the anterior, lateral and posterior lung fields
    • Diminished? Crackles? Wheezes?
• Chest
  • Visual inspection for bruising and rashes
  • Palpate for tenderness and crepitus
  • Does the chest rise symmetrically?
  • Breast buds? Cellulitis?
• GI
  • Look for hepatosplenomegaly
  • Is there Epigastric tenderness?

Chest Pain in Children: A Reasonable Work-up

• The goal is to balance risk of the rare with risk of over-testing.

• EKG
  • Reasonable screen for cardiac etiology [Kane, 2010]:
    • Chest Pain with Exertion?
    • High-risk family history (ex, unexplained sudden death, drowning)?
    • Abnormal exam (ex, murmurs, hepatomegaly)?
  • Abnormal EKG
    • Remember, non-exertional chest pain + normal EKG = low risk for cardiac pathology, but not ALL pathologies
• CXR
  • For a child with autism, a CXR could help you find a foreign body or look for a pneumonia
  • In a child with hemoglobin SS, an infiltrate could be a fat embolism or pulmonary infarct
• POCUS
  • If pneumothorax is your primary concern, POCUS is your friend
  • There are plenty of studies  that demonstrate that U/S is more sensitive than supine CXR in the setting of adult trauma.
    • U/S – ~90% sensitive
    • Supine CXR – ~50% sensitive
    • Erect CXR has increased sensitivity (~90%), naturally.
  • POCUS can quickly rule out a clinically significant pericardial effusion also

Moral of the Morsel

• For the young patient presenting with chest pain, be vigilant, but be reasonable!
• Screen for risk factors of sudden cardiac death.
• Screen for badness with:
  • Thorough history and directed physical exam
  • EKG
  • POCUS and CXR