The differential diagnosis for pediatric chest pain is extensive (Table 6-1).
TABLE 6-1Differential Diagnosis of Chest Pain |Favorite Table|Download (.pdf) TABLE 6-1 Differential Diagnosis of Chest Pain
Myocardial infarction or ischemia
Pneumonia ± pleural effusion
Esophageal foreign body
Slipping rib syndrome
Precordial catch syndrome (Texidor's twinge)
No organic or psychological cause identified
A cardiac cause for pediatric chest pain is found in 4% to 5% of cases presenting to the ED.1,3 Myocardial infarction is rare in the pediatric population, but has been reported in the literature in previously healthy adolescents.5 These patients usually present with the classic severe, substernal chest pain with radiation to the left arm or jaw; however, it is important to note that the location and severity of a child's chest pain is not specific to myocardial infarction or a cardiac etiology.1–3,5 Patients are at greater risk for myocardial ischemia if they have a history of congenital heart disease, acquired heart disease (e.g., Kawasaki disease), or drug abuse (e.g., cocaine), thus a thorough history and physical examination is imperative.
Pericarditis and myocarditis are cardiac diseases that cause chest pain. Both conditions can present with fever and chest pain, although myocarditis usually has a more insidious onset. Pericarditis usually presents with sharp, substernal chest pain that is alleviated by leaning forward. On physical examination, the patient classically has distant heart sounds, a friction rub, and signs of congestive heart failure (CHF). Myocarditis patients often have vague symptoms including chest pain, dyspnea, dizziness, nausea, vomiting, and fatigue. Physical examination usually reveals a gallop, signs of CHF, and tachycardia unresponsive to fluids. A concerning history and physical examination should prompt the practitioner to consider myocarditis and pericarditis.
Structural abnormalities of the heart and vessels can cause chest pain. Hypertrophic cardiomyopathy patients usually give a history of increased chest pain with exertion. Aortic stenosis, pulmonary stenosis, abnormal coronary arteries, and mitral valve prolapse, depending on the severity, can lead to ischemia of the heart and papillary muscles. History and physical examination of these patients typically reveal a heart murmur associated with the lesion.
Arrhythmias can cause chest pain in children. Premature ventricular tachycardia can present as a fleeting, sharp pain, or palpitations. Supraventricular tachycardia (SVT) is usually described as a rapid heartbeat. Physical examination should cue the physician to the possibility of SVT.
In children, a pulmonary etiology for chest pain was found in 12.5% to 19% of cases.1,2,4 Patients presenting with a history of asthma or reactive airway disease should prompt the physician to assess for the possibility of chest pain secondary to an asthma exacerbation. Bronchospasm and persistent coughing can lead to excessive use of the chest wall muscles and is a common cause of chest pain.
Pneumonia with or without pleural effusion can also cause chest pain. Presenting signs and symptoms would usually include fever, tachypnea, and upper respiratory symptoms. Physical examination may reveal decreased breath sounds or crackles.
Patients who report acute pain and subsequent respiratory distress should raise suspicion for a spontaneous pneumothorax or pneumomediastinum. The typical patient with a spontaneous pneumothorax is a tall thin boy presenting with an abrupt onset of unilateral chest pain.6 Patients with asthma, Marfan's syndrome, or cystic fibrosis are at increased risk for developing pneumothoraces. Physical examination may reveal decreased breath sounds on the affected side and crepitus depending on the extent of the pathology. A hemothorax should also be considered if there is a history of trauma.
Pulmonary embolism is rare in pediatrics, but should be considered in adolescents who complain of dyspnea, pleuritic chest pain, hemoptysis, and low-grade fever. Risk factors for a pulmonary embolism are the use of birth-control pills, recent abortion, prolonged immobility, inherited hypercoagulable disorders, indwelling central lines, and major trauma, particularly to the lower extremities.
Gastrointestinal (GI) causes for pediatric chest pain make up 3% to 4% of ED visits.1,3 Gastroesophageal reflux disease causes a burning, substernal pain. Epigastric tenderness on physical examination and the association of the pain with food is suggestive of a GI origin.1,7
Children who have ingested a foreign body that is lodged in the esophagus can have chest pain. Patients may have dysphagia depending on the location of the foreign body.
A musculoskeletal etiology for chest pain is found in 32.5% to 43% of ED visits.2,4 Trauma can cause fractures and contusions that may result in chest pain. Overuse or overexertion of the chest wall muscles may cause muscle strain.
Costochondritis is a common condition recognized by the practitioner when chest pain is elicited by palpating the costochondral joints. The etiology of costochondritis is unknown, but it is considered to be a benign, inflammatory condition. A similar disease, Tietze's syndrome, also occurs at the costochondral junctions, but has the associated findings of swelling, redness, and warmth. Like costochondritis, Tietze's syndrome is thought to be a self-limited inflammatory condition.
Slipping rib syndrome usually occurs at the false or floating ribs. The patient usually describes a sharp, intermittent pain that lasts a few minutes and settles to a dull ache. There may be a history of trauma and aggravation with movement. The etiology of the pain is thought to result from the anterior end of the rib, slipping out of place and aggravating the adjacent intercostal nerve. The “hooking maneuver” can be used to help diagnose this condition. The patient is instructed to lie on the unaffected side and the practitioner reaches under the lower costal margin and pulls the rib anteriorly. A positive test results in the reproduction of the patient's pain and a click sensation.
Precordial catch syndrome, or Texidor's twinge, is a benign condition that causes a brief, sharp pain to the left chest without radiation. The pain may occur with exercise or when the patient is at rest in a slouched position. The etiology is unclear, but is thought to occur from the parietal pleura, intercostal nerves, or from the stretching of the supporting ligaments of the heart.
Chest wall pain that follows a dermatome should raise the physician's suspicion for a herpes zoster infection. This is not a musculoskeletal condition, but deserves mentioning as the patient's pain may precede the skin lesions.