Chest pain in children

Question 1

Probability diagnosis

Answer 1

Musculoskeletal (chest wall pain):

• cough strain (10%)
• injury
• muscle strain
• costochondritis
• precordial catch syndrome (stitch in side)
• asthma

Note: Most cases are unknown (21%).

Question 2

Serious disorders not to be missed

Answer 2

Vascular:

• ischaemic pain: structural cardiac conditions
• arrhythmias (e.g. PSVT)

Infection:

• pericarditis
• myocarditis
• pneumonia
• herpes zoster

Other:

• pneumothorax
• POTS syndrome

Question 3

Pitfalls (often missed)

Answer 3

Kawasaki syndrome

Breast disorders

Rarities:

• Bornholm disease
• oesophagitis or gastric pain

Question 4

Is the patient trying to tell me something?

Answer 4

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

Question 5

Key history

Answer 5

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

Associated symptoms such as fever, cough, dizziness, overexertion, syncope and recent viral illness.

FHx, esp cardiac disease including unexplained sudden death, recent stressful events and drug history.

Question 6

Key examination

Answer 6

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

Question 7

Key investigations

Answer 7

No investigation usually required

Consider ECG and CXR

Question 8

Diagnostic tips

Answer 8

Most cases are of unknown aetiology and probably psychogenic.

Chest pain is more common in adolescents.

<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
• children with sickle cell anaemia.