Elsevier

Journal of Pediatric Health Care

Volume 14, Issue 1, January–February 2000, Pages 3-8
Journal of Pediatric Health Care

ORIGINAL ARTICLE
Chest pain in children: diagnosis through history and physical examination

https://doi.org/10.1016/S0891-5245(00)70037-XGet rights and content

Abstract

ABSTRACT

Introduction: Chest pain is a common complaint in the pediatric age group and can be a physically and emotionally distressing symptom. Although chest pain in children rarely indicates serious cardiac problems, chest pain is perceived as “heart pain” to most children and their families and presents a diagnostic challenge to health care providers. Methods: A prospective study was conducted to identify specific factors in history taking and physical examination that permit accurate diagnosis of the cause of pediatric chest pain. Fifty children (ages 5–21 years; mean, 13 years), referred to the cardiology clinic with the chief complaint of chest pain, underwent systematic history taking, physical examination, and electrocardiogram testing. Results: The following diagnoses were made: 38 children (76%) had musculoskeletal/costochondral chest pain, 6 children (12%) had exercise-induced asthma, 4 children (8%) had chest pain resulting from gastrointestinal causes, and 2 children (4%) had chest pain resulting from psychogenic causes. Discussion: All the children in this study had noncardiac causes of their chest pain. This finding supports previous research suggesting that chest pain in children is rarely of cardiac origin. This article reviews the causes of pediatric chest pain and suggests an approach to its evaluation and management. J Pediatr Health Care. (2000). 14, 3–8.

Section snippets

Structural anomalies

Chest pain in a child with a murmur may suggest an obstructive lesion such as aortic stenosis or cardiomyopathy. Sharkey and Clarke (1991) explained that children with significant aortic stenosis can have chest pain during exercise. The aortic stenosis causes limited ability to increase cardiac output. This limited response in cardiac output causes a fall in systemic vascular resistance during exertion, thus resulting in coronary artery underperfusion and subsequent myocardial ischemia.

Pericardial or myocardial inflammatory processes

Myocarditis usually follows a viral illness. Many children have fever, respiratory distress, nonspecific chest pain, anorexia, and malaise. Often they have an S3 gallop on examination. The electrocardiogram can reveal ST segment depression and T-wave abnormalities, and a chest x-ray may reveal cardiomegaly. In contrast, pericarditis resulting from infection or autoimmune disorders frequently appears with acute onset of sharp chest pain that is lessened by leaning forward. Physical examination

Arrhythmias

Arrhythmias can also be manifested as chest pain in children. Chest pain may result from a rhythm disturbance based on alterations in cardiac output. Sharkey and Clarke (1991) report that the most common arrhythmia in infants and children is supraventricular tachycardia (SVT). Findings include a rapid heart rate of approximately 200 beats per minute, pallor, grayish coloration, diaphoresis, and in significant episodes, hypotension and syncope. Electrocardiogram findings can include narrow

Methods

This prospective study was designed to diagnose the cause of chest pain in children. Aconvenience sample of 50 consecutive children referred to the cardiology clinic with the chief complaint of chest pain was included in the study. Data were collected during a 4-month period. The children were determined to be eligible for the study if they had no prior cardiology evaluations, did not have a pre-existing cardiac diagnosis, and were referred by their primary care provider because of the sole

Results

The findings of the cardiac examination for all subjects were within normal limits. Twenty-nine percent of the subjects had innocent murmurs that were noted on examination. Thirty-six percent of the subjects had easily reproducible chest pain. On average, the chest pain began 2 weeks to 2 months before referral, occurred on a daily to weekly basis, lasted seconds to minutes, and was self-limited. Of the 50 electrocardiograms obtained for the children with chest pain, 4 (8%) were read as

Discussion

Chest pain in children is a common complaint with an often benign origin. Common noncardiac causes include musculoskeletal/costochondritis, a pneumonic process, a gastrointestinal cause, or a psychogenic cause. However, some cardiac abnormalities in children result in chest pain. Therefore, the most important tools for assessing a child with chest pain are thorough history taking, including a history of present chest pain complaints and family history, and physical examination. This systematic

Limitations

Because every child in the study did not receive an echocardiogram, some subtle structural abnormalities may have been overlooked, such as mild MVP, mild mitral regurgitation, or mild pulmonic stenosis. However, these trivial diagnoses generally do not produce or precipitate chest pain. In addition, children with complaints of associated rapid heartbeats with their chest pain may not have had a documented arrhythmia while participating in the study. However, it is reassuring that at 1 year

References (17)

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Reprint requests: Juli-anne K. Evangelista, MS, RNc, CPNP, Cardiovascular Program, Children's Hospital, Boston, 300 Longwood Ave, Boston, MA 02115.

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