Chest Pain

Chest pains are quite common in children and in contrast to adults chest pain in children and teenagers arising from the heart is extremely rare. Musculoskeletal or respiratory causes are far more common. Worrying signs for chest pains are when they consistently occur with exercise or stress, are associated with other symptoms eg preceded by palpitations or occur in patients known to have structural cardiac disease.

Idiopathic

Chest pain in children is usually benign and rarely due to a cardiac cause. The precordial catch (benign chest pain of unknown cause) is the commonest cause experienced by most of us at one time or another. It may occur at rest or during exercise, is located usually at the apex but may be found at the sternal edges. It is usually described as a sharp stabbing pain of short duration. It is particularly common in adolescent girls. Its frequency varies from once every now and again to several times a day. If very frequent it can be disabling. There are no other abnormal symptoms or signs of cardiac disease. An ECG and if available an echocardiogram are often therapeutic. It improves with sympathy, time and reassurance.

Musculoskeletal

This is usually a sharp pain and usually easily recognised by its relationship to trauma and movement. It is usually well localised and can often be reproduced by pressure on the affected area or “springing” the ribs. It is usually acute and subsides over days. Tietze’s syndrome appears to be a costo-chondritis usually of the 2nd to 5th costo-chondrial junctions. Swelling of the junctions may occur. Spontaneous resolution is invariable.

Cardiac

Arrhythmia – In SVT or VT the high cardiac oxygen requirement may outstrip the supply. The usual presenting complaint is however a noticeable fast heart rate with the chest pain a secondary phenomenon.
Aortic valve disease, if severe, may present with chest pain on exercise. A 12 lead ECG even at rest is likely to show some ST-T segment changes which become marked on exercise. An echocardiogram is also likely to show LVH, a LVOT velocity greater than 4 m/s and or severe aortic regurgitation.
Pericarditis usually presents in the context of a systemic illness with chest pain alleviated on sitting up. An ECG may show ST elevation and echocardiogram an effusion.
Hypertrophic cardiomyopathy rarely presents with chest pain especially in childhood. If it occurs it is usually central chest pain on exercise.
Kawasaki syndrome may present with myocardial ischaemia if the coronary arteries are affected. This is very unusual in the acute phase tending to occur in those with coronary artery sequelae. Other vasculitides (e.g. Takayasu) may present in a similar fashion.
Congenital abnormalities of the coronary arteries may present with chest pain. In the infant this may be pallor and crying on feeding whilst exercise induced pain is more common in the older child. The ECG will be abnormal and the echocardiogram should confirm the diagnosis.
Pulmonary hypertension, especially in those with Eisenmenger’s syndrome may develop chest pain with exercise. This may be due to RV ischaemia. Vasodilators e.g. nitrates are useful, as may venesection if polycythaemia is severe.
Aortic dissection may occur in the older patient with Marfan syndrome. The classical signs of the syndrome will be present. The chest pain is often in the back and described as tearing. Suspected cases should have a CXR, TOE or CT/MRI scan.
Rheumatic fever may cause pericardial pain secondary to inflammation.
Drug abuse e.g. cocaine, glue sniffing may cause coronary arterial spasm.

Respiratory

Classical pleuritic pain is usually easy to distinguish from cardiac pain due to its location and variation with respiration. Signs of respiratory disease are often also present (dyspnoea, tachypnoea, haemoptysis, fever and abnormal breath sounds). Pericardial pain may occasionally be difficult to distinguish.

Gastro-Intestinal

Oesophagitis due to reflux may occur but it is uncommon except in those with abnormal uncommon GI tracts. Peptic ulcers are probably under-diagnosed in childhood and may present with epigastric or chest pain. Vomiting and other symptoms of reflux, haematemesis or melaena may point to the diagnosis. A reasonably reliable sign is upper epigastric tenderness

Psycho-Somatic

This may be a learned phenomenon as chest pain in later adult life is often of a serious nature. Adult role models may thus initiate the symptoms that are then used as an excuse to avoid unwelcome activities. A careful history and examination with judicious investigation should allow appropriate management.

Management

Appropriate diagnosis of the cause of the chest pain and reassurance are usually all that is required. An ECG often helps reassure and exercise test may be helpful if the chest pain is associated with exercise or in the context of structural cardiac disease. If epigastric tenderness is present GI endoscopy may be appropriate.

This page was last edited 16/2/2004

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