1. Chest Pain In Children and Adolescents Caroline L. Derrick BSN, RN
University of Michigan

2. Most causes are Benign Common Complaint from Children in ER
Known association with myocardial infarction (MI) and sudden death in adults
In children, Cardiac causes are the least likely in association with presenting chest pain.
9/18/2018

3. Studies
Nurse Practitioner Study: 50 Children with CP referred to Pediatric Cardiologist- non-cardiac cause.
3/1,000 children visiting ER for CP, only 1% were cardiac in nature
LT outcomes in idiopathic CP- 81% reported no CP after 3 year follow up.
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4. Differential Diagnosis
Musculoskeletal
Respiratory GI
Idiopathic
Psychogenic
Cardiac
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5. Musculoskeletal Pain
Muscle Strain: Chest wall pain- usually associated with strain of muscles and may occur with excessive exercise or trauma.
Strain of the upper back or pectoral muscles
Direct trauma to the chest- athletics, accidents, physical abuse. Trauma may include rib fractures, intercostal muscle strain, pneumothorax or hemothorax.
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6. Costochondritis 10-22% Childhood CP
Local, sharp pain in the mid-sternal area
Reproducible pain with palpation along costochondral margins
May last for several months
More common in girls
Treatment: Reassurance, NSAIDS, rest
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7. Slipping Rib Syndrome
Sprain disorder r/t trauma to 8th, 9th, 10th ribs
Sensation of ribs “slipping”
Pain with flexing the trunk, turning over, deep breathing, prolonged walking, coughing
Positive “hooking maneuver”
Treatment: reassurance, injection of local anesthetic, possible surgical removal of affected cartilage.
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8. Respiratory Causes
Pneumonia and Asthma may cause excessive coughing, may continue to overuse chest wall muscles.
Pleural Effusions- pain exaggerated by deep breathing
Pneumothorax- Chest pain
Tachypnea, retractions, wheezing, fever, decreased breath sounds.
CXR, SpO2%, peak flow meter levels
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9. Gastrointestinal Pain
2-7% of all causes of CP in adolescents
Esophagitis/GERD- “burning”, aggravated in a reclined position.
Pain with eating meals or spicy foods
Foreign body ingestion- toddlers; lodged in proximal esophagus
Caustic Ingestions- household cleaners- damage to esophagus
*** Bulimia Nervosa- purging- esophagitis/ perforation.
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10. Idiopathic CP Most common cause of childhood/adolescent CP
No organic or psychogenic cause after thorough history, PE, labs
Emotional stress/Anxiety, especially in girls
Hyperventilation Syndrome- hypercapnic alkalosis. Associated with lightheadedness, HA and parasthesias
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11. Rare Causes of CP Thoracic tumor Sickle Cell Disease Herpes Zoster
Ectopic Pregnancy
Precordial Catch- Texidor’s Twinge- Syndrome associated with CP. Described as brief
(less than 5 minutes), sharp, shooting, left sided pain
Pain subsides with shallow breathing and straightened position
Thought to be produced by pressure on intercoastal nerve
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12. Cardiac Causes of CP- Congenital Anomalies
Mitral Valve Prolapse(MVP)
Most prevalent cardiac lesion associated with CP in children/adolescence
Associated with thickening of mitral valve leaflets- bulge into the annulus.
Pain results from Left ventricular endocardial ischemia as the valve prolapses
30% of MVP patients report CP
Mid-systolic ejection “click”
Systolic ejection murmur id regurgitation is present
9/18/2018

13. Cardiac causes of CP- Congenital Anomalies
Left ventricular outflow obstruction- group of lesions that produce a significant risk for ischemic myocardial dysfunction.
Aortic Stenosis (AS) common- progressive over time- associated with bicuspid aortic valve
Causes a decrease in CO
CP with exertion
PE- systolic ejection click, systolic murmur over aortic valve region and palpable thrill at suprasternal notch
Aortic Stenosis Murmurs become louder when going from standing to squatting.
EKG- hypertrophy patterns may be present
9/18/2018

14. Cardiac causes of CP- Congenital Anomalies
Subaortic Stenosis/ IHSS- obstructive lesions also associated with CP with exercise and exertion.
Harsh systolic murmor heard from squatting to standing.
IHSS inherited lesion- autosomal dominant pattern
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15. Cardiac causes of CP- Congenital Anomalies
Anomalous Origin of the Left Coronary Artery- rare
Limited coronary artery blood flow, causing ischemia
Angina type pain, syncope
PE- Pan systolic continuous or mitral regurgitant murmur may be heard as well as a gallop.
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16. Acquired Conditions
Pericarditis- infectious process causing inflammation of the pericardium
Sharp, shooting pain
Precordial in location
Often relieved by leaning forward
Cough fever, respiratory distress may be present
PE- heart sounds may be distant, muffled; a rub may be auscultated
Rub may disappear with development of pericardial effusion
EKG: ST segment or T wave change
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17. Acquired Conditions
Kawasaki Disease- a history of this disease with coronary artery involvement, presenting with CP should be considered for myocardial ischemia.
Immunoglobulin treatment- without 20-25% children have coronary artery involvement at the time of presentation.
If administered within 10 days, incidence falls from 3-5%
Children with coronary artery abnormalities almost always have left ventricular hypertrophy
EKG: Abnormal ST segment or inverted T waves are noted in precordial leads.
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18. Acquired Conditions
Cardiomyopathy- general term used to describe ventricular dysfunction
Many types- only some present with CP
Fatigue, decreased exercise tolerance, palpitations
Dilated Cardiomyopathy may have CP with exertion and a systolic murmur.
Ask about a familial history of sudden cardiac death when a child has dilated cardiomyopathy.
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19. Acquired Conditions Myocarditis preceded by viral illness
Children may have a fever, malaise, nonspecific CP, respiratory distress.
PE- may produce evidence of a gallop
Chest radiograph- cardiomegaly
ECG- ST segment depression and T wave abnormalities
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20. Arrhythmias
SVT (Supraventricular tachycardia)- may cause CP. Most common childhood arrhythmia
Rapid heartbeat>200 bpm
PE: diaphoresis, pallor, hypotension, syncope
Can convert to SR with vagal Stimulation
Frequent episodes of syncope, treatment options include: pharmacologic therapy
(Adenosine) or ablation
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21. Arrhythmias Ventricular Tachycardia (VT)- rare but associated with CP
Wide complex tachycardia
Rate bpm
Medical Emergency- may progress to Ventricular fibrillation
Causes: viral myocarditis, surgically induced sequelae or prolonged QT interval.
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22. Questions to Ask: Past Medical History
History of: asthma, sickle cell disease, rhematic fever, cystic fibrosis?- CP may indicate a complication.
History of congenital or acquired heart disease? Even if it was fixed may produce CP.
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23. Severity of CP Scale “0-10” or smiley faces Worst pain ever?
Interfere with daily activities?
What makes the pain better? Worse?
Any associated factors related to the chest pain?
Organic vs. Psychogenic pain
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24. Onset, Frequency, Duration
When did the pain start?
What were you doing when the pain started?
How often does the pain occur?
When does the pain occur? What activities are you doing?
How long does the pain last, is it continuous or does it come and go (intermittent)?
How long has this been going on?
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25. Type and Location
How would you describe the pain? Sharp, dull, burning, pressure, etc?
Sharp pain- costochondritis, musculoskeletal, may be located along costochondrial junction
Burning- espohagitis, indigestion, may be located at midsternal area.
Where is the pain located, does the pain radiate (travel) to any other areas? (jaw, neck, shoulders, abdomen, arm, etc.)
Sharp pain that radiates to the neck, back and shoulders may be associated with pneumomediastinum
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26. Associated Symptoms Palpitations Dizziness Syncope with CP
*** These symptoms are associated with cardiac causes of CP and should be taken seriously
Recent Flu like symptoms, prolonged fever with new onset of CP- endo, pericarditis, myocarditis- immediate work-up required
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27. Precipitating Factors
Anxiety- explore recent events- new school?, etc.
Tend to complain of CP during the week but not on weekends, holiday breaks or summer.
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28. Family Events Ill family member? Divorce? Physical or sexual abuse?
Girls: BCP- rare Pulmonary embolism
Depression- stressors
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29. Family History Pivotal
History of acquired or congenital heart disease, Marfan Syndrome or history of arrhythmia
Critical- history of sudden cardiac death in a family member
Idiopathic hypertrophic subaortic stenosis- autosomal dominant disorder associated with sudden cardiac death.
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30. Physical Exam Complete Signs of severe distress, pain, anxiety
Vital signs,BP and weight within range for age?
Assess respiratory function for distress or abnormalities
Ecchymosis, trauma, rash, chest heave, abnormal shape of chest, scoliosis or syndromic appearance.
Tall and thin with long fingers and toes? (Marfan Syndrome)
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31. Physical Exam
Palpate chest wall to attempt to reproduce or locate source of CP
Include clavicals, entire chest wall, breasts and zyphoid area
Assess for palpable thrill or RV heave- both consistent with congenital and acquired heart disease
Subcutaneous emphysema- trauma or spontaneous pheumothorax?
Palpate abdomen- tenderness and assess for hepatosplenomegaly
9/18/2018

32. Physical Exam Palpate extremities for warmth and general perfusion
Assess pulses in all four extremities for equality and strength
Hooking maneuver
Auscultate the heart for murmurs, gallops, rubs, dysrhythmias and any other abnormal heart sounds
Auscultate in supine, sitting , standing and squatting positions- helps to hear murmurs of AS and sub AS.
Lie patient on left side- assess for murmur of mitral regurgitation or mitral valve click
Auscultate all lung fields assess for wheezes, rales, or asymmetry of breath sounds
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33. Further Evaluation Labs usually not needed
In most cases, H& P will clarify cause
Consider peak flow meter if asthma may be the cause
Order CXR if signs of pleural effusion, pneumothorax, pneumonia, chest trauma, or bone fracture
Consider pregnancy test
12 lead ECG
Holter Monitors, journal/diary
Journal/diary of events surrounding CP
Exercise Stress Testing- cardiac rhythm during exercise
Referral if cardiac in origin
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34. Good Prognosis
CP in children/adolescents common and rarely cardiac related
Thorough H & P essential to rule out rare and life threatening causes of CP
Most causes of CP are benign and cause no further sequelae.
9/18/2018