Jennifer Thull Thull-Freedman, MD, MSCI, FAAP(PEM)
Assistant Professor of Paediatrics
University of Toronto
Co Co-director, PEM Clinical Fellowship
The Hospital for Sick Children
From my residency
 A 12-year year-old previously healthy boy presented to
the ED after first seeking care at the neighborhood fire
department for chest pain
 Told to take a warm bath for muscle aches
 Arrived several hours later alert but in pain
 HR=130, BP not done
 CXR obtained
 Child waited in room for CXR to be reviewed
From my residency
 Child suddenly became unresponsive and pulseless
 Unable to be resuscitated
 CXR reviewed during resuscitation showed
 widened mediastinum
 Autopsy revealed dissection of the aorta
However
 Most cases of chest pain in children are not related to
serious pathology
 History and physical exam often sufficient evaluation
The challenge
Objectives
 Review relevant literature
 Review common causes of chest pain in children
 Discuss uncommon but serious causes
 Present an approach to the child with chest pain
 Summarize take take-home points
Etiology of chest pain in kids
 Very few studies
 Most retrospective
 Variable inclusion/exclusion criteria
 Limited detail provided
Selbst et al
 Objectives:
 Identify causes of chest pain in children
 Assess value of echocardiogram
 Prospective
 Enrolled all patients with chest pain
 ECG and echo offered to those with ill ill-defined or
suspected cardiac etiology
 PediatricsPediatrics1988; 82: 3191988; 319--323323
Selbst et al.
 Population
 407 patients
 Philadelphia, Pennsylvania
 Median age 12.5 years
 55% female, 90% African African-American
 43% acute pain <48 hours
 Did not exclude known disease
 PediatricsPediatrics1988; 82: 3191988; 319--323323
Selbst et al.
 ECG ECG’s in 191/235 children
 31 abnormal (16%)
 27 minor or previously known findings
 3 dysrhythmias detected on physical exam
 1 with known SLE had findings of pericarditis
 PediatricsPediatrics1988; 82: 3191988; 319--323323
Selbst et al.
 Echocardiograms in 139/235
 17 abnormal (12%)
 12 mitral valve prolapse (8.6%)
 Similar prevalence to general population
 2 pericardial effusion
 2 mitral valve regurgitation
 1 poor LV function
 PediatricsPediatrics1988; 82: 3191988; 319--323323
Selbst et al.
 Chest radiographs in 137/407
 37 abnormal (27%)
 Most frequent: infiltrates, atelectasis, hyperinflation
 1 pneumothorax in a child with Marfan Marfan’s
syndrome
 1 clavicle fracture suspected clinically
 1 child with SLE had pleural effusion, large heart
 PediatricsPediatrics1988; 82: 3191988; 319--323323
Selbst et al.
 Organic disease related to
 Age <12 years
 Pain awakening child from sleep
 Acute onset
 Abnormal physical exam
 Not related to description or location of pain
 PediatricsPediatrics1988; 82: 3191988; 319--323323
Selbst et al. #2
 6-month follow follow-up of 149/407 patients
 43% had intermittent or persistent pain
 No significant disease identified
 1 mitral valve prolapse
 1 gastrointestinal disease
 3 asthma
 Conclusion:
 H&P sufficient for identifying majority of significant
etiologies
Clinical PedsPeds1990; 29: 3741990; 374--77
Rowe et al.
 Chest X X-rays done in 50%
 18/161 with positive result
 15 infiltrates
 2 pneumomediastinum
 1 pneumothorax
 ECG done in 18%
 2/60 with significant new findings
 Tachycardia and ST changes suggested myocarditis
 WPW
CMAJCMAJ1990; 143:3881990; 388--9494
Massin et al.
 9 cases cardiac etiology in 168 PED patients
 3 SVT
 2 MVP
 4 sick sinus
 1 myocarditis
 1 pericarditis
 1 cardiac hemochromatosis with β-thalassemia
 5 cases cardiac etiology in 69 card. clinic patients
 5 SVT
Clin Pediatr 2004;43:231 231
Massin et al.
 Results
 Palpitations or abnormal auscultation predicted all
cases of cardiac disease
 Conclusions
 Chest pain in children usually benign
 History and physical usually sufficient
 Laboratory testing guided by H&P
Clin Pediatr 2004;43:231 231-
Limitations of current literature
 Small numbers for characterizing rare events
 Limited detail
 Children with known disease not excluded
 Lack of follow follow-up
 No evidence evidence-based guidelines
Differential Diagnosis
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Chest wall
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Gastroesophageal
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Reflux
Foreign body
Pulmonary
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Trauma
Costochondritis
Precordial catch
Slipping rib
Infection
Mastalgia
Zoster
Asthma
Pneumonia/effusion
Pneumothorax
Pleurisy
Pulmonary embolus
Malignancy
Hematologic
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Sickle cell disease
Psychogenic
Differential Diagnosis
 Cardiac
 Angina
 Coronary abnormalities
 Hypercoagulable state
 Cocaine
 Obstructive heart disease
 IHSS, aortic stenosis
 Pericardial effusion/pericarditis
 Arrhythmias
 Myocarditis
 Aortic aneurysm
Cases
 Case
 A 12-year year-old girl presents to the emergency
department with chest pain for 2 days
 Started gradually
 Worse with deep breath
 Had URTI last week
 Afebrile
 Tender on both sides of sternum
 Remainder of physical exam normal
Costochondritis
 Inflammation of costochondral cartilage
 Cause
 Overuse
 Preceding URTI with cough
 Idiopathic
 Sharp pain, worse with movement
 All ages
 Tenderness over costochondral joints
Case
 A 10 10-year year-old boy presents to the ED with
recurrent episodes of left chest pain.
 Feels like a sudden stab
 Can’t take a deep breath
 Lasts 2 2-3 minutes
 Occurs at rest
 Not reproducible
 Normal physical exam
Precordial Catch Syndrome
 “Texidor’s twinge”
 Sudden, brief
 Occurs at rest
 Localized
 Sharp
 Exacerbated by deep breath
 No associated symptoms
 No physical findings
Case
 A 6 6-year year-old girl comes to the emergency
department after having chest pain at home.
 Stopped playing, became clingy, said chest hurt
 Mom thought she looked pale
 Now looks and feels better
 HR=110, normal physical exam
SVT
 In children >1 year


82% present with palpitations
14% with pain
 14% perspiration
 14% dizzy
 4% pallor
 1-3% of chest pain complaints in ED
 6% of chest pain referred to cardiologist
 Median time from symptoms to diagnosis 138d
Case
 A 13 13-year year-old boy presents to the emergency
department with sudden severe chest pain
 Sharp pain in anterior chest
 Appears anxious
 BP 80/40 in right arm
 Diastolic murmur
Marfan syndrome
 Caused by fibrillin gene mutation
 Manifestations
 Musculoskeletal: Tall, long limbs and fingers, pectus
 Ocular: Lens dislocation
 Cardiovascular: Aortic root dilation, MVP
 Pulmonary: Spontaneous pneumothorax
 50% have aortic root dilation by age 10 years
 90% have aortic root dilation by age 20 years
Aortic dissection
 Children at risk
 Marfan syndrome
 Ehlers-Danlos
 Coarctation
 Aortic stenosis
 Turner syndrome
 Endocarditis
 Cocaine use
Case
 A 17-year year-old female presents to the ED with chest
pain that has lasted for 1 hour
 Pain began during soccer practice
 Has happened previously with exercise
 Midsternal, squeezing, radiates to left arm
 PMH: Admitted to hospital for FUO at age 2 years
Kawasaki Disease
 Acute febrile vasculitis of childhood
 Features
 Fever (>39 degrees for 5 days)
 Non Non-exudative conjunctivitis
 Erythema of oral mucosa and tongue
 Erythema and swelling of hands and feet
 Cervical adenitis >1.5 cm
 Rash
 Leading cause of acquired heart disease in kids
Cardiac sequelae of KD
 Acute and subacute
 Myocarditis (50% of patients)
 Pericarditis
 Mitral, aortic insufficiency
 Arrhythmias
 Coronary aneurysms
 20 20-25% if untreated
 5% if treated with IVIG
 Appear 7 days to 4 weeks after onset of fever
Cardiac sequelae of KD
 Long-term follow follow-up (> 10 years) of 594
untreated patients
 IVIG treatment standard since late 1980 1980’s
 24.6% had coronary aneurysms
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
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49% had regression
19% developed stenosis (4% of total)
8% developed myocardial infarction (2% of total)
Circulation1996;94:1379-85
Myocardial ischemia in kids
 Anomalous coronary arteries
 Prevalence 2:1000
 Anomalous origin of L coronary from pulm. Artery
 Presents in first months of life
 Irritability, heart failure, cardiac enlargement
 Anomalous origin from incorrect sinus of Valsalva
 Presents later in childhood
 Compression between aorta and pulm Artery
 Hypoplastic coronary arteries
Myocardial ischemia in kids
 Sickle cell disease
 Myocardial infarction uncommon but described
 Perfusion defects in 5% children studied in a Paris sickle
cell clinic ( Arch Dis Child 2004;89:359 359-62)
 Microvascular occlusion of small vessels
 Exchange transfusion may be helpful for acute ischemia
( Pediatrics 2003;111:e183 e183-7)
Myocardial ischemia in kids
 Nephrotic syndrome
 Thrombotic occlusion of coronary arteries
 Long Long-standing diabetes mellitus
 Familial hypercholesterolemia
 SLE, Antiphospholipid antibody syndromes
 Cardiac transplant
 Cocaine abuse
Case
 A 16-year year-old boy presents to the emergency
department after fainting at a track meet
 Remembers having chest pain during his race
 Father died suddenly in his 30 30’s
 Systolic murmur on exam
Hypertrophic cardiomyopathy
 Autosomal dominant
 Symptoms in 2 2nd nd decade
 May present with angina angina-like pain or syncope
 Impaired diastolic relaxation, increased O O2 demand
 Risk of sudden death 6% in children
Hypertrophic cardiomyopathy
 Case
 A 6-year year-old girl presents to the ED with cough
for 3 weeks and chest pain for 1 week
 Feels very tired
 Illness began with URTI 3 weeks ago
 Afebrile
 Heart rate = 160
 Liver palpable 3 cm below RCM
Myocarditis
 Usually viral etiology
 Enterovirus (coxsackie), adenovirus
 Presentation
 Heart failure
 Chest pain
 More likely in older kids and adults
 Ischemia or concurrent pericarditis
Myocarditis
 Physical findings
 Tachycardia, tachypnea
 Poor perfusion
 Muffled heart sounds, S3, murmur
 Hepatomegaly
 CXR
 Cardiomegaly
 Pulmonary edema
Myocarditis
 ECG
 Sinus tachycardia
 Decreased voltages (<5 mm) limb leads
 LVH
 Prolonged PR interval, prolonged QT interval
 Echocardiogram
 Hypokinesis, impaired function
Hypertrophic cardiomyopathy
 Case
 A 6-year year-old girl presents to the ED with cough
for 3 weeks and chest pain for 1 week
 Feels very tired
 Illness began with URTI 3 weeks ago
 Afebrile
 Heart rate = 160
 Liver palpable 3 cm below RCM
Pericarditis
 Infectious etiology common in children
 Pain
 More common in older children and adolescents
 Worse when supine, relieved by leaning forward
 Physical findings
 Friction rub if effusion small
 Muffled heart sounds, pulsus paradoxus if large
Pericarditis
 ECG
 Low voltages
 ST elevation

Usually leads I, II, V5, V6
 Electric alternans
 Produced by swinging motion of heart within effusion
Case
 A 9-year year-old obese boy is brought to the ED at
11 pm complaining of chest pain since dinner preventing
him from sleeping
 Has been having episodes for few weeks
 Described as burning
 Worse after big meals and when lying down
 Normal physical exam
Gastroesophageal Reflux
 Berezin et al.
 27 children 8 8-20 years with idiopathic chest pain all
received EGD, manometry, pH monitoring
 Not blinded, no control group
 Results: 78% had gastroesophageal cause
 16 of 27 (59%) had esophagitis
 4 of 27 (15%) had gastritis
 1 of 27 (4%) with abnormal manometry
Gastroesophageal Reflux
 Accounts for 5 5-10% of PED chest pain visits
 Classic pain is temporally associated with meals
 Burning, retrosternal
 Trial of antacid, H2RA, PPI is appropriate
 Consider pH probe if diagnostic testing needed
Case
 A 3 3-year year-old boy is evaluated in the emergency
department with chest pain for several hours
 Points to sternal notch
 Drooling
 Refusing juice
 Afebrile, well well-appearing
 Breath sounds equal
Esophageal foreign body
 Case
 An 8 8-year year-old boy is brought to the ED directly
from a hockey practice during which he said his chest
hurt and he couldn couldn’t breathe
 Several similar episodes
 Feeling better since arrival to ED
 Tight cough
 Normal breath sounds, no murmur
 Normal CXR and EKG
Asthma
 May account for 10 10-20% chest pain in kids
 Personal or family history atopic conditions
 Associated with cough
 May be worse at night or with exercise
 Wheezing not always detectable
 Trial of bronchodilator
 Consider PFT for pain with exercise
Case
 A 17 17-year year-old boy presents to the emergency
department with right chest pain
 Just returned hours ago from vacation in Cozumel
 Pain began one day ago
 Progressive dyspnea during flight home
Pneumothorax/pneumomediastinum
 Children at risk
 Asthma, bronchiolitis
 Barotrauma
 Cough, choking, vomiting
 Crack, cannabis
 Cystic fibrosis
 Marfan syndrome
 Tall male teenagers
Case
 A 15-year year-old girl presents to the ED with chest
pain
 Present for several days
 Reports feeling dizzy and short of breath
 Not associated with exercise
 Physical exam unremarkable
 Grandmother died last week of heart attack
Psychogenic
 Psychogenic
 5-20% of chest pain in children
 More common in adolescents
 Recent or current stressful situation
 Family illness, especially cardiovascular
 Family history of chest pain
 Other somatic and sleep complaints
 Depression
The approach: History
 Description of pain
 Not as reliable in children as in adults
 Precipitating factors
 Exertion
 Eating
 Deep breathing
 Muscle use
 Trauma
 Emotional stress
The approach: History
 Frequency and chronicity
 Associated symptoms
 Fever
 Cough
 Shortness of breath
 Syncope
 Dizziness
 Palpitations
The approach: History
 The approach: History
 Past medical history
 Known heart disease
 Asthma or atopic conditions
 Prothrombotic conditions



Cancer
SLE
Nephrotic syndrome
 Medications and drugs
 Family history
The approach: Physical exam
 General appearance
 Body habitus
 Vital signs
 Chest wall palpation
 Auscultation
 Abdomen
 Peripheral perfusion
Red flags
 Pain associated with exercise, palpitations, or syncope
 Shortness of breath
 Pain limits daily activities or disturbs sleep
 Substance abuse
 Presence of prothrombotic conditions
 PMH consistent with Kawasaki disease
 Family history of sudden death or early cardiac death
 Abnormal vital signs or physical findings
The approach
 Further evaluation
 CXR
 ECG
 Holter monitor
 Echocardiogram
 Cardiology consultation
 Therapeutic trials
Summary
 Chest pain in pediatrics usually due to benign,
 identifiable etiology
 Cardiac and other life life-threatening causes of
 chest pain rare but do exist
 Often can be ruled out by history and physical exam
 Diagnostic tests appropriate in presence of red flags