Evaluation of Chest Pain in Children

Educational Objectives

The goal of this program is to improve the management of chest pain in children. After hearing and assimilating this program, the clinician will be better able to:

1. Differentiate between cardiac and noncardiac chest pain in children.
2. Diagnose postural orthostatic tachycardia syndrome in children and adolescents.
3. Identify the differential diagnosis of chest pain in the pediatric population.

Summary

Chest pain: the 2 primary pain sources are visceral and somatic; cardiac pain is a subtype of visceral; most sudden cardiac events are not associated with abnormal examination results or imaging; rarely cardiac-related in children, especially otherwise healthy children with no history of heart issues or family history of early cardiac events; emerging modifiers related to chest pain include hypermobility and palpitations, particularly concerning in the context of postural orthostatic tachycardia syndrome (POTS), which has become more prevalent during the COVID era

Causes: Alnaim et al (2023) — examined children presenting with chest pain to a pediatric outpatient setting, with echocardiography (ECHO) performed for diagnostic purposes and found the majority of chest pain was not cardiac-related, with idiopathic chest pain and musculoskeletal issues being the most common causes, followed by respiratory; cardiac issues accounted for only ≈6%; the authors concluded that chest pain is usually benign, and ECHO is of little diagnostic value; however, it is still important to identify the small percentage of cardiac-related cases; heart defects — atrial septal defect, ventricular septal defect, and patent ductus arteriosus are not associated with chest pain

Cardiac-related chest pain: can stem from various issues, including ischemia, inflammation, heart muscle diseases, systemic outflow obstructions, and tearing of the heart muscle; characteristics typically include pressure, tightness, and squeezing, often radiating to the neck or back and associated with activity or exercise; additional symptoms may include nausea, vomiting, sweating, shortness of breath, and tachycardia; in outpatient settings, diagnostic options are limited, often relying on clinical evaluation without access to additional imaging or laboratory tests

Role of electrocardiography (ECG) in diagnosis: an ECG can provide additional information to support clinical suspicions, particularly by detecting ST changes; however, pediatricians often encounter challenges differentiating normal variants from potential cardiac events, especially in children with chest pain; biomarkers (eg, high-sensitivity troponin) are available but may not be routinely utilized in outpatient settings

Noncardiac symptoms: salient features associated with noncardiac chest pain include sharpness, positional nature (aggravated or relieved by certain positions), shifting location, pleuritic nature, reproducibility on examination, and fleeting duration, typically resolving spontaneously after a few seconds

Evaluation: most pediatric patients presenting with chest pain are healthy without prior heart concerns or family history; clinical evaluation should include inspection of the chest wall, as abnormalities here can often indicate noncardiac causes of chest pain; however, examining the chest can be challenging, especially with modest adolescents (requires sensitivity and respect for patient privacy); gathering a comprehensive medical history remains essential in assessing chest pain, considering factors, eg, aggravating factors, duration, and relevant medical background

Noncardiac causes of chest pain: overuse and muscle strain often occur in young children engaged in activities (eg, tumbling, gymnastics), leading to inflammation and discomfort in the chest muscles; increased participation in competitive sports and weight training among children can contribute to muscle stress and soreness; respiratory issues (eg, reactive airway disease, asthma) are also prevalent, especially during seasonal changes; symptoms may include wheezing, coughing, and allergic features (eg, bluish discoloration under the eyes, nasal creases); a prolonged expiratory phase is a subtle but suspicious sign; an empirical trial of a β2 agonist prior to activity may be warranted; evaluating lung function through tests (eg, pulmonary function testing, treadmill exercise testing) can aid in diagnosis and guide treatment strategies

Musculoskeletal causes: costal chondritis and precordial catch syndrome are the most common causes of chest pain in the outpatient setting; costal chondritis manifests as sharp, stabbing pain worsened by inspiration and localized to a specific area of the chest, and pain is reproducible upon examination; precordial catch syndrome presents with similar pain specifically over the heart area, and pain is not reproducible

Pectus excavatum: the most common cause of chronic chest pain in adolescent girls, in the speaker’s experience; adolescent girls may feel uncomfortable showing their chest area, and health care providers aim to respect their privacy; pectus excavatum can be challenging to detect, especially in individuals with developing breast tissue, as it may resemble the normal contour of the chest; characterized by a funnel or concave chest; pectus carinatum is a broad or “pigeon” chest; they are defects in the breastbone or sternum that can be familial and associated with cartilage diseases or syndromes (eg, Marfan syndrome); unless moderate to severe or causing symptoms, not necessarily chest pain, pectus rarely requires treatment; consider referral to a chest wall clinic or pectus clinic

Mastalgia: breast pain or discomfort is common in adolescent girls, often because of physiologic fibrocystic changes during breast development or inadequate support from ill-fitting bras, particularly in cases of larger breasts; gynecomastia is common in boys, often caused by medications, certain body types, or obesity; can occur unilaterally or bilaterally, causing pain or discomfort in the breast area

Slipped rib syndrome: involves a defect in the cartilage of the lower ribs, causing chest pain typically in the lower chest area; patients may experience clicking or popping sounds, with pain sometimes radiating to the side; the hooking maneuver involves hooking the lower chest and pulling up while listening for a clicking or popping sound; ultrasonography may aid in diagnosis; referral to orthopedics or general surgeons may be necessary for treatment

Hypermobility: refers to joint instability and an ability to extend joints beyond the normal range of motion; can cause chronic body pain and chest discomfort, often because of chronic dislocations; a characteristic of Ehlers Danlos syndrome (EDS); distinguishing between hypermobility spectrum and hypermobility EDS is crucial; patients with hypermobility EDS need a referral to cardiology with a concern for aortic or mitral valve changes; patients with hypermobility spectrum do not need cardiology; diagnosis utilizes the Beighton scoring system, which assesses hyperflexibility in various joints, including fingers, thumbs, elbows, knees, and spine; a positive test is a score of 5 to 6, depending on age; in individuals with hypermobility EDS, cardiac concerns include dilation of the aortic root or ascending aorta, increasing the risk for aortic root dissection

Postural orthostatic tachycardia syndrome: characterized by symptoms upon positional changes; in pediatric patients, diagnosis requires a heart rate increase of >40 beats per min (BPM), symptoms that persist for 2 to 3 mo, and absence of orthostatic blood pressure (BP) changes; dysautonomia POTS presents with systemic symptoms (eg, vision changes, headaches, rashes), whereas typical POTS presents with chest pain, fast heartbeat, lightheadedness, and fainting; treatment approaches differ based on the type of POTS; vasovagal syncope and orthostatic intolerance need to be ruled out; vasovagal syncope typically occurs in response to a trigger; orthostatic intolerance involves feeling lightheaded or faint every time one stands up, usually because of BP issues; traditionally, tilt table tests were used to assess POTS, but currently, orthostatic testing alone is often sufficient

Treatment: involves exercise, maintaining vascular tone, hydration, and medications when necessary; initiating medication is often based on the impact of symptoms on daily life, especially school attendance; medications include volume expanders, (eg, pyridostigmine [Mestinon, Regonol], fludrocortisone [Florinef]), with β-blockers also being effective in controlling heart rate; suspicion arises when patients with a diagnosis of POTS have not been prescribed β-blockers, suggesting potential misdiagnosis

Orthostatic testing: involves transitioning from lying supine to sitting to standing positions during which heart rate and BP should typically increase; this response is a protective mechanism to ensure adequate blood flow to the brain when standing up quickly; occasionally, this system may fail temporarily, causing symptoms, eg, light headedness, a sensation of nearly passing out; vasovagal syncope involves a decrease in heart rate and BP in response to a trigger; in postural or orthostatic intolerance, heart rate is maintained and BP decreases; with POTS, heart rate increases >40 BPM (children) or >30 BPM (adults), and BP may decrease slightly

Referral to cardiology: indicated for chest pain associated with syncope, exercise, murmur that increases with standing, prolonged fever, history of heart surgery, family history of cardiomyopathy, or abnormal testing

Readings

Alnaim AA, AlGarni HW, Al Ghadeer HA, et al. Characteristics of chest pain among children presenting to the pediatric emergency department. J Med Life. 2023;16(11):1606-1610. doi:10.25122/jml-2023-0280; Aygun E, Aygun ST, Uysal T, et al. Aetiological evaluation of chest pain in childhood and adolescence. Cardiol Young. 2020;30(5):617-623. doi:10.1017/S1047951120000621; Balta S, Arslan D. Pain pressure thresholds in children and adolescents with idiopathic chest pain. Cardiol Young. 2022;32(2):252-256. doi:10.1017/S1047951121001840; Barbut G, Needleman JP. Pediatric chest pain. Pediatr Rev. 2020;41(9):469-480. doi:10.1542/pir.2019-0058; Danon S. Chest pain, palpitations, and syncope: Preventing sudden cardiac death in children. Adv Pediatr. 2023;70(1):171-185. doi:10.1016/j.yapd.2023.04.003; O'Meara D. Chest pain in children. JAMA Pediatr. 2023;177(10):1112. doi:10.1001/jamapediatrics.2023.2566.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Dixon was recorded at the 47th Annual Melvin L. Cohen, MD, Pediatric Update Conference 2024, held March 4-7, 2024, in Scottsdale, AZ, and presented by Phoenix Children's Hospital. For information about upcoming CME activities from this presenter, please visit https://phoenixchildrens.org/providers/continuing-medical-education. Audio Digest thanks the speakers and Phoenix Children's Hospital for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

PD702302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

More Details - Certification & Accreditation