By Santa J. Bartholomew M.D. FAAP, FCCM
Chest pain in children and adolescents is a common complaint in both outpatient settings and in the emergency department.
This is an anxiety provoking symptom for patients and their parents because of the fear from the adult literature of the cardiac origin of chest pain in adults. However, in children with chest pain the incidence of cardiac related causes is 0.2 to 1%. Most etiologies for chest pain in children are grouped into several categories:
- Musculoskeletal (19.75%)
- Pulmonary (8.39%)
- Gastroenterologic (10.36%)
- Psychogenic/Psychological (16.31%)
- Cardiac (9.75%)
- Idiopathic (36%) in some instances
Even though cardiac causes are very small etiologically they do and must take precedence in the evaluation of a child with chest pain because of the catastrophic consequences if missed. Determining the cause of chest pain relies heavily on a thorough history and physical examination.
Etiological Chest Pain Categories
Evaluation for Chest Pain
- Very careful and complete history and physical examination: this will help guide the direction of testing. For each of the diseases listed there are often key historical features that can guide work-up.
- There should be specific questioning about cardiac history, including personal and family history of syncope which may suggest cardiac issues. Family history regarding diabetes, connective tissue disorders like Marfan’s, Ehlers-Danlos, Kawasaki disease should be explored.
- If cardiac etiology is suspected there is a standardized clinical assessment and management plan tool (SCAMP) that guides work up. Using this tool has provided a 22% cost reduction in evaluation and treatment of chest pain and to try to provide uniformity to evaluation.
- When evaluating children with chest pain providers SHOULD ALWAYS consider conditions that may predispose children to cardiac death such as Long QT syndrome (20% of these patients have family history), hypertrophic cardiomyopathy (one third have family history), catecholaminergic polymorphic VT (VT brought on my exercise) and anomalous origin of the coronary artery.
Questions That Should Always Be Asked
- Have you ever fainted, passed out, or had a seizure suddenly and without warning, especially during exercise or in response to auditory triggers such as doorbells, alarm clocks, and ringing telephones?
- Have you ever had exercise-induced chest pain or shortness of breath?
- Are you related to anyone with sudden, unexplained, and unexpected death before age 50 years?
- Are you related to anyone who has been diagnosed as having a sudden death–predisposing heart condition such as hypertrophic cardiomyopathy, long QT syndrome, or catecholaminergic polymorphic ventricular tachycardia?
In evaluating a child with chest pain careful, methodical, and thorough history is key in guiding your evaluation!!