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Chest Pain in children: when to worry and when to refer

Dr Katy Huxstep, Dr Owen Miller and Dr Sarah Brooke

Firstly the good news! Although chest pain is a common symptom in children, that we often see in our Emergency Departments and outpatient clinics – children are rarely found to have a cardiac cause of their chest pain.  

However, it is a symptom which can cause a lot of anxiety to our patients and their parents (and of course ourselves!) and there are some serious and/or life threatening conditions you absolutely don’t want to miss.

Read on for our tips on how to assess chest pain in children. We’ll demonstrate how to provide a comprehensive approach and ensure the red flags are covered when it comes to history taking, assessment and further investigation.

History and Examination

As with most things in paediatrics, a decent history will usually give you a good impression of what is likely to be causing the pain.

Take a thorough pain history and ask about associated, aggravating and relieving factors; pain that comes with exercise is a red flag for a possible cardiac cause. Musculoskeletal chest pain is usually localized and reproducible (with a gentle prod as you examine). Radiation to the neck, jaw and left arm – as with chest pain in adults – suggests myocardial ischaemia. With pericarditis, pain can radiate to the left shoulder and be worse when the child is lying down flat. Chronic chest pain is less likely to be cardiac.

You also need to know about any recent surgery, illnesses and exercise intolerance – have they ever had to stop exercising because of pain, or collapsed during strenuous exercise? Ask specifically about weight loss, fevers, drug use, palpations and any stress they are feeling at home or at school. For older children and teenagers, make sure you take a few minutes to talk to them alone and cover the HEADSSS assessment.

Past medical history is really important! Ask about asthma, sickle cell, acid reflux, headaches, and Kawasaki disease. Children who’ve had cardiac surgery or other cardiac interventions such as previous arterial switch operation, Ross procedure and transcatheter stents or devices, could later present with chest pain.

Family history of sudden death, connective tissue disorders, genetic abnormalities, arrhythmia or cardiomyopathies hints towards possible inherited cardiac conditions.

Any of these red flags in your history should trigger urgent further investigation:

  • Exertional chest pain – specifically DURING exercise
  • Significant palpitations with chest pain
  • Sudden syncope especially during exercise
  • Significant family history of arrhythmia, sudden death or genetic disorders

Generally speaking, the most common cause for chest pain in children is musculoskeletal (think reproducible pain, tenderness on palpation and pain worsening with movement/ coughing).

Respiratory causes are also common, associated with lower respiratory tract infection and inflammation (think about bronchospasm or pleuritic chest pain).

Gastro-oesophageal symptoms eg. reflux or constipation typically cause retrosternal and epigastric pain.

Other causes to consider include herpes zoster, sickle cell, trauma and psychological (with hyperventilation, could it be anxiety?)

A ‘traffic light’ approach

With such a wide range of differentials we’ve put together a traffic light structure to assessment.

RED: needing immediate review by a specialist cardiology center

AMBER: features that strongly suggest a cardiac cause – refer to a Paediatrician with expertise in Cardiology

GREEN: reassuring features that suggest a non-cardiac cause, can be routinely managed by a General Paediatrician

Investigations

Start with a full set of observations and an ECG – easily available and an essential initial investigation in chest pain. Without going into an in-depth review on paediatric ECG analysis; (have a good read of the basics here) you should look at rate, rhythm, hypertrophy determination (using normal values for age), and look for signs of pericarditis and ischaemia.

Chest X-Ray is not usually needed unless there’s a history of acute severe pain, pain when waking, cough, fever, history of trauma, or abnormal examination findings.

Blood tests are not often needed. Dependent on history, bloods could include FBC, ESR, CRP, blood cultures and viral isolation. Troponin is generally not needed.

An echocardiogram (echo) is not needed in all cases, and is normally done as an outpatient investigation – an echo wouldn’t usually be

done in the acute setting unless the child was severely unwell or cardiovascularly unstable.

Echocardiograms can help to get a closer look at…

  • Pericardial effusions
  • Cardiomyopathy
  • Ventricular dysfunction
  • Left sided obstructive lesions
  • Aortic root measurements and assessment for dissection
  • Heart valve function
  • Coronary arteries (origins and appearance)
  • Pulmonary hypertension
  • Assessment of intracardiac cardiac devices

Further investigations – if there’s a history of palpitations, a 24-hour ambulatory ECG can be used to try and capture any episodes of arrhythmia and identify atrial or ventricular arrhythmia or heart block.

An exercise stress test (for exertional chest pain.)

Treatment is of course dependent on the cause. Rest, reassurance and analgesia are often what’s needed, particularly when no cardiac cause is found. For pericarditis and pericardial effusions, ibuprofen can be started (after discussing with the Level 1 or Level 2 cardiologist) along with a plan for regular monitoring and review.

Key points

Chest pain has a wide range of differentials: make sure you know the red flag features for cardiac chest pain

Have a systematic approach to chest pain history to not miss important clues

An ECG is your first point of call, echo may be normal and will focus on specific cardiac differentials for chest pain

Refer to the ‘traffic light’ system when deciding whether to refer for specialist review

Dr Katy Huxstep, Consultant Paediatrician with Expertise in Cardiology, Royal Cornwall Hospitals Trust; Dr Owen Miller, Paediatric Cardiologist, Evelina Children’s Hospital; Dr Sarah Brooke, Paediatric ST1, Royal Cornwall Hospitals Trust

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The information found on this site is the personal opinion of the authors, and is intended to educate and interest, rather than to direct clinical management for specific patients. Copyright is shared between the author/s and this site. You may reproduce this content as long as the original source is credited. No information on this site may be reproduced for profit. 2018, paediatricfoam.com