COVER STORYFRANK M. GALIOTO, Jr., MD

DR- GALiOTO is a pediatric cardiologist atChild Cardiology Associates and PediatrixMedical Group, and Inova Hospital forChildren, both in Fairfax, Va. He is also aclinioal professor of pediatrics at GeorgetownUniversity School of Medicine and theUniversity of Virginia School of Medicine. Theautinor has nothing to disciose with regard toaffiliations with, or financiai interest in, anyorganization that may have an interest in anypart of this article.

In our very cardiac-conscious society, a child presenting with chest painusually creates anxiety in his or her parents, who fear for the worst.Despite the family's worries, which can be considerable, the tnany causesof chest pain are usually benign. In rare cases, however, it can be the har-binger of significant cardiac disease. Pediatricians should therefore com-

plete a preliminar}' evaluation for chest pain, decide on a differential diagno-sis, and if not make a specific diagnosis, at least develop a diagnostic plan tolearn its cause. Often a definite diagnosis calls for the aid of an appropriateconsultation. With this assistance, a treatment plan can be established. »

MAY 2007 CONTEMPORARY PEDIATRICS 47

CHEST PAIN

A variety of sourcesThere are many causes ol chest pain inchildren (Table 1). Unlike in adults, wherethe risk of cardiac-based chest pain is con-siderable, cardiac etiologies of chest painin children are uncommon.'' Despite alow prevalence of such occurrences, theconsequences of misdiagnosis are none-theless grave.

That said, pediatricians should be ableto identify a child at risk, and recognizethat although a speciftc anatomic cardiacdiagnosis is the job of the cardiologist,

Table 1

Possible causes of chest painin children and adolescents

1. Muscutoskeletala) Strained intercostal or

pectoralis inusclesb} Injured rib or sternal

cartilagec) Bruised or fractured rib

or sternum

2. Pulmonarya) Reactive airway disease,

at rest or induced byexercise

b) Bronchitisc) Pneumoniad) Pleurisye) Pneumothorax

3. Gastrointestinala) Esophagitisb) Gastroenteritisc) Gastric ulcer

disease

4, Cardiaca) Hypertrophic

cardiomyopathyb) Anomalous coronary

arteryo) Premature

atherosclerotic coronaryartery disease

d) Sequelae of Kawasakidisease

e) Pericarditis andmyocarditis

f) Arrhythmia, paroxysmalatrial, or ventricular

5) Psychogenic(especiallyin older

children)

thai diagnosis can only be made if thepatient is first referred on by his or heralert pediatrician.

By far the most common cause of chestpain among children is musculoskelelalinjury.''^ Children can easily injure theirpectoral or intercostal muscles as well thecartilaginous structures of the immaturechest wall in sports, heavy lifting, or evenplayground activity'. In smaller children.this problem is often confounded by thechild's inability to clearly state the natureof the problem. Similarly, vague com-plaints of chest pain are often dilficult toseparate from abdominal pain—especiallyin children under six years of age.' (See"A hands-on approach to chest painassessment" on p a g e 50.) Less preva-lent causes include those pulmonary inorigin, typically a bronchospasm, either atrest or induced by exercise.^

Finally, underKing cardiac problems,while usually rare, can also present asanother source for chest pain among chil-dren. The focus of this article will be onthe differential diagnosis of these cardiac-based etiologies.

Author's note: Non-cardiac causes in-cluding gastroesophageal reflux andasthma will not be discussed in this arti-cle. But they have been well covered byother authors.'"*

Asking the right questionsAs in all diagnostic evaluations, a thor-ough history is important, even in a youngchild. The pediatrician should first askwhen the pain started, even though theanswer is usually a vague "last month" oreven "last year." In general, the longer thepain has been present without progres-sion, the less likely it is life-threatening.

Once the pediatrician has established atime frame, the next questions should be ^about the most recent episode (hopefully, gthe last episode was in recent memory so 5

48 www. contemporary pediatrics, com Vol. 24, No. 5

CHEST PAIN

Taken

Time descriptions

are difficult in

young chiidren, so

use a relationship

they know, like the

length of a TV ad,

to see how long

ttie pain lasted.

tbe child can describe it well). Ask howlong the pain lasted, what made it better,and what made it worse. Was tbere acbange in the pain with arm movement orrespiraiion? Was there trouble breathing?Was the breatbing noisy? Was tbere dizzi-ness? Was the pain caused by any partic-ular activity? If the pain comes at rest, askwhether it was like a pin or a pencil eraserpressing against one area of tbe chesl.Time descriptions are difficult in youngchildren, so using a relationship tbat tbeywould know, i.e., the length of a TV com-mercial, can help determine how long tbepain lasted.

In the history, the pediatrician shouldinquire about activities both current andin tbe recent past. Occurrences of painwith physical activities sucb as wrestling,weight lifting, gymnastics, dance, and

swimming sbould be identified. In a chestwall injur>' (see Table 2 on page 53),tbe pain may not come during tbe activitybut rather hours or even a full day later. Ifyour patient plays a sport, it's importantto ascertain whether or not tbe patientstretched and warmed up adequatelybefore competing.

If a young child bas been swinging fromtbe monkey bars, question wbetbcr tbepain is on tbe non-dominant side. Mostindividuals are right-handed, so the leftside may be inherently weaker. Wcigbt-tifting or monkey-bar type of play causesequal stress on botb sides of tbe chestwall, and may lead to a strained pectorallsmuscle or even a rib eage separation ontbe non-dominant side. Tbere may be nopain during ibc specific activity, but aftera cool-down period of up to a day or two.

Inspecting and palpatingthe chest wall is vital toidentify the cause of chestpain; auscultation of theheart and lungs are lessvaluable. When palpating,check the rib spacings,muscular size, andconsistency. Compare oneside of the chest to theother, since a swollenpectoralis muscle that isalso tender upon palpationmeans a chest wall injury.If fhe space between theribs is uneven andthe area is in pain, thediagnosis becomes clear.Often just pressing onthe chest wall will elicitthe same pain thatbrought the child tothe office.

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CHEST PAIN

there can be sudden chest cramping. Ingeneral, pain that comes at rest is usuallybenign; pain brought out by exercise canbe more significant.

Parents' assumptions can also be a fac-tor in the early phases of chest pain. If thepain is emanating from the left side, thepatient's family usually assumes that it is"heart pain," a warning sign for a heartattack. This erroneous conclusion, intum, leads to an urgent call to the pedia-trician. Questioning parents about familyhistor)' also plays a crvtcial role. Pediatri-cians should take a careful family history,paying attention to any congenital heartdisease, hypertrophic cardiomyopathy. orpremature coronary artery disease. A fam-ily history of unexplained sudden death isan alarm bell for an extensive workup in achild with chest pain, especially if the paincomes with activity.'^

The heart of the matterwhile less prevalent than chest wall in-juries, cardiac causes of chest pain arewithout question a reality. HyperLrophiccardiomyopathy, for its part, is the leadingcause of sudden death during sports inchildren and adolescents in the US.' Inthis cardiac muscle disease, the myocar-dium thickens and literally outgrows itsown blood supply. The already compro-mised myocardium becomes more is-chemic with activity, and chest pain candevelop. If the ischemia persists, a fatal ar-rhythmia may occur as the myocardiumbecomes electrically unstable.

The resting physical examination inthese patients often reveak no obviousabnormalities. There may be a grade 1/6short ejection systolic murmur or no mur-mur at all. In order to further evaluate themurmur, have the patient hop or do jump-ing jacks to increase cardiac output andleam if this activity produces a more signif-icant murmur. Squatting or changing body

Table 2

Chest paindialogue

1) When did thepain start?

2) How long did the pain last? What has made it better/v^orse?

3) Was there a change in the pain with arm movement orrespiration?

4) Was there trouble breathing? Was the breathing noisy?

5) Was there dizziness?

6) Was the pain caused by any particular activity?

7) Was the pain like a pin or a pencil eraser pressing againstone area of the chest?

8) Ask about activities (dance, gymnastics, swimming, weightlifting, wrestling), both current and in the recent past. Didthe patient stretch and warm up adequately beforecompeting?

9) Is the pain on the non-dominant side?

10) Is there a family history of any congenital heart disease,such as hypertrophic cardiomyopathy, or prematurecoronary artery disease?

position may not have the same effect.Similarly, a coronar\- artcr)' could have

an anomalous course that passes betweenthe pulmonary artery and the aorta. Thatanomalous course could cause compres-sion of the coronar)' artery during periodsof activity when both the aortic and pul-monary' artery pressures increase to meetthe body's need for a higher cardiac out-put. Such compression could producelife-threatening ischemia, arrhythmia, andeven sudden death.'*'

Murmurs are common in children, andmost are usually innocent. A pathological

PointTaken"

A family history of

unexplained

sudden death is

an alarm bell.

MAY 2007 CONTEMPORARY PEDIATRICS 53

CHEST PAIN

Taken

Every full diagnostic

workup should

include an

echocardiogram

as well as an

electrocardiogram.

murmur is a clear indication for a full car-diac workup, especially if associated withchest pain. Unfortunately, murmurs areusually ahscnt or misdiagnosed as inno-cent in potentiall)' lethal causes of chestpain. The pediatrician's total evaluationdecides if a cardiac referral is needed, notthe presence or absence of a murmur.

Chest pain arising from rare etiologiesmust also he considered. One uncom-mon cause is chest pain from coronarystenosis from early atherosclerotic dis-ease or Kawasaki disease." The role ofKawasaki disease in premature coronaryatherosclerosis is the subject of muchstudy. Myocarditis and pericarditis canlead to chest pain, hut this is usually amore consistent discomfort and is notrelated to activity. Any child who has aparoxysmal arrhythmia, either atrial orventricular in origin, can have inade-quate coronary blood flow during theperiod of arrhythmia, leading to coro-nary insufficiency, ischemia, and chestpain. The patient should always be asked

to identify any change in heart rate thatmay have preceded the onset of chest pain.Dizziness with chest pain can be a veryominous sign, with or without syncope,and deserves a full cardiac evaluation.

Tools of the tradeIf one suspects that there is a cardiac etiol-ogy, the diagnostic workup by the cardiol-ogist should include an electrocardiogram(ECG) and echocardiogram (echo). AnECG may reveal pre-excitation of theWolff-Parkinson-White variety, whichwould predispose the child to an arrhyth-mia. There could also he a prolonged QTinterval corrected for heart rate on theECG, which could serve as a predictor forventricular tachycardia of the torsades depointes variety.

Signs of underlying congenital heartdisease include atrial cnlargetnent or ven-tricular hypertrophy. Detailed echocar-diograms should, therefore, reveal the sizeand function of the left ventricle. In hy-pertrophic cardiomyopathy there is typi-cally asymmetric septal hypertrophywith d)Tiatnic left ventricular outflowobstruction. A thin and dilated myo-cardium with poor function would he asign for a dilated cardiomyopathy, whichcould also present with cardiac ischemia.The echo should also track the coronaryartery origins from the aortic root, lookingfor an anomalous course.

Stress testing should he undertaken ifthe sytTiptoms are induced by exercise andthe ECG and echo are non-diagnostic.^Stress testing may hring out an exercise-induced arrhythmia, such as ventricularuchycardia produced by an epinephrinesurge. Event monitors and Holler moni-tors may also be used to look for paroxys-mal arrhythmias.

Cardiac CT and/or contrast-enhancedMRI have been extremely helpful in iden-tifying anomalous coronary arteries that

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CHEST PAIN

are suspected from the echo.^ Cardiaccatheterization could be used to define theanatomy further, but this is usually notnecessarv' with an adequate cardiac CTand/or MRI. The child who has a com-pletely nonnal ECG during exercise doesnot have ischemia. If there is a question-able exercise ECG or ongoing chest painol unknown etiology, the child shouldhave a coronary ischemia workup, includ-ing cardiac enzymes with special attentionto troponin.' You should obtain fastinglipid panel tests looking for hypercholes-terolemia or other lipid disorders, andhemoglobin level tests looking for pro-found anemia.

Healing & outlookIn those cases where a chest wall injury ispresent, treatment should begin withreassuring the patient and the family thatihis is not a cardiac event. Recommendrest of the injured muscles, even if ittneans stopping a sport. Non-steroidalanti-inflammatoty agents such as ibupro-fen can relieve the pain and swelling of achest wall injury. You should emphasizethat this does not cure the injury, justlessens tbe acuity of the symptoms. Ap-plying heat to the affected area sometimeshelps. After no pain for a month, start

References

1. Evangilisla HA, Parsons M, Renneburg AK: Chestpain in children: diagnosis through history and physi-cal examination. J Pediatr Health Care 2000:14:32. Cava JR, Sayger PL: Chest pain in children andadolescents. Pediatr Clin North Am 2004;51:15533. Rowe BH, Dulberg CS, Peterson RG, et al: Charac-teristics of children presenting with chest pain to apediatric emergency department. CMAJ 1990;143:3884. Estes NAM, Salem DN. Wang PJ (eds.): Suddencardiac death in the athlete. Armonk, N.Y., FuturaPubiishing Co.. Inc., 19985. De Feyter P, Krestin GP (eds): Computed tomogra-phy ot the coronary arteries. Abingdon, UK, InformaHealthcare. 20046. Basso C, Maron BJ, Corrado D, et al: Clinical pro-file of congenital coronary artery anomalies with originfrom the wrong aortic sinus leading to sudden deathin young competitive athletes. J Am Coll Cardiol2000:35:1493

range of motion exercises. If they do notcause pain, the patient can start strength-ening the chest wall with very lightweights and multiple repetitions. If thepain is still gone with the use of lightweights, the child can return to playingsports. Be sure to explain to your patientthat heavy or power weight lifting isnever indicated."^"

While chest pain in children and ado-lescents Ls common, iTs usually not a life-threatening malady. In most cases theyhave a chest wall injut^', and treatmentconsists of general support and reassur-ance. Rarely, the pain will be a warning ofa ver>' serious problem. With a compre-hensive history and physical examination,the pediatrician should be able to eitherdiagnose and treat, or refer to the correctconsultant. Atypical pain, initiated byactivity, perhaps associated with dizzyspells or syncope, and especially if there isa family history of suddeti death, is anindication for prompt referral. If there isdoubt as to the diagnosis, it is always bet-ter to tnake a referral rather than risk acatastrophic outcome. D

For more informationon pediatric cardiology, see

V Conteinpc-;..::, f\ •.•• • .. . y

\ Resources (CPR) on page 88. /

7. Ostman-Smith k Wettrell G. Keeton B, Bt al:Echocardiographic and electrocardiographic identifi-cation of those children with hypertrophic cacdiomy-opathy who should be considered at high-risk of dyingsuddenly. Cardiol Young 2005:15:6328. Kawasai<i disease: A medical dictionary, bibliogra-phy, and annotated guide to Internet references. NewYork, N.Y., Icon Health Publications, 20049. Paridon SM. Alpert BS, Boas SR. et al: Clinicalstress testing in the pediatric age group: A statementfrom the American Heart Association council on car-diovascular disease in the young, committee on ather-osclerosis, hypertension, and obesity and youth. Cir-cuiation 2006; 113:190510. Bar-Or O (ed.): The child and adolescent athlete.IOC Medicai Commission. Oxford. UK, Blackwelt Sci-entific. 199611. Birrer RB. Griesemer B, Cataletto M: Pediatricsports medicine for primary care. Philadelphia, Lippin-cott, Williams & Witkins, 2002

Taken

While chest pain

in children and

adolescents is

common, it's

usually not a

lite-threatening

malady.

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