Chest Pain in Children: Clinical Evaluation Learning Tool

Clinical History Assessment

Systematic approach to history taking for a child presenting with chest pain

Physical Examination Guide

Systematic approach to examining a child with chest pain

Diagnostic Approach

Initial Assessment

For a child presenting with chest pain, the initial assessment should include:

• Detailed history focusing on character, location, duration, and radiation of pain
• Complete physical examination with focus on cardiac, respiratory, and musculoskeletal systems
• Assessment of associated symptoms and precipitating factors
• Exploration of psychosocial context and stressors

Key Clinical Features

Understanding the most likely causes based on presentation:

Clinical Feature	Associated Conditions	Key Characteristics
Pain Character	- Sharp, stabbing: Musculoskeletal, pleuritic - Crushing, pressure: Cardiac - Burning: Gastroesophageal	Character of pain helps narrow differential diagnosis
Duration	- Brief (seconds): Precordial catch - Prolonged (hours): Inflammatory - Very brief but recurrent: Costochondritis	Duration pattern helps distinguish etiology
Associated Symptoms	- Fever: Infectious causes - Dyspnea: Cardiac or respiratory - Syncope: Cardiac arrhythmia	Associated symptoms provide diagnostic clues
Exacerbating Factors	- Exercise: Cardiac, asthma - Deep breathing: Pleurisy, pneumonia - Emotional stress: Anxiety, panic	Factors that worsen pain can guide diagnosis

Differential Diagnosis

System	Conditions	Red Flags
Cardiac	- Myocarditis/pericarditis - Arrhythmias - Coronary artery anomalies - Aortic dissection - Hypertrophic cardiomyopathy	- Exertional chest pain - Syncope/near-syncope - Pain radiating to jaw/arm - Family history of sudden death - Abnormal cardiac exam
Respiratory	- Pneumonia - Pleurisy - Pneumothorax - Pulmonary embolism - Asthma	- Hypoxemia - Respiratory distress - Fever with productive cough - Sudden onset severe pain - Risk factors for thromboembolism
Musculoskeletal	- Costochondritis - Precordial catch syndrome - Trauma - Muscle strain - Tietze syndrome	- History of significant trauma - Pain worse with movement - Localized tenderness - Visible chest wall swelling
Gastrointestinal	- Gastroesophageal reflux (GERD) - Esophagitis - Esophageal foreign body - Peptic ulcer disease	- Postprandial pain - Dysphagia - Hematemesis - Chronic recurrent symptoms - Association with position change
Psychogenic	- Anxiety/panic disorders - Hyperventilation syndrome - Somatization - Stress-related	- Associated with stressful events - Concurrent anxiety symptoms - Multiple somatic complaints - Pain varies with attention
Other	- Herpes zoster - Sickle cell crisis - Toxin exposure (e.g., carbon monoxide) - Breast development (in adolescents)	- Dermatomal distribution - Known sickle cell disease - Multiple family members affected - Unilateral breast tenderness

Laboratory Studies

Consider these studies when red flags are present:

Investigation	Clinical Utility	When to Consider
Complete Blood Count	Assess for infection, inflammation, anemia	Fever, suspected infection, inflammatory condition
Cardiac Enzymes (Troponin)	Evaluate for myocardial injury	Cardiac features, concerning history for myocarditis
BNP/NT-proBNP	Screen for heart failure	Dyspnea, cardiac exam abnormalities, suspected myocarditis
D-dimer	Screen for pulmonary embolism	Risk factors for thromboembolism, unexplained hypoxemia
Electrocardiogram (ECG)	Evaluate for arrhythmias, ischemia, pericarditis	Any suspected cardiac etiology, exertional pain, syncope

Advanced Studies

Reserve for concerning presentations:

Investigation	Clinical Utility	When to Consider
Chest X-ray	Evaluate for pneumonia, pneumothorax, cardiomegaly	Respiratory symptoms, fever, trauma, cardiac concerns
Echocardiography	Assess cardiac structure and function	Abnormal ECG, cardiac exam abnormalities, exertional symptoms
Exercise Stress Test	Evaluate for exertional ischemia	Exertional chest pain, family history of premature coronary disease
CT Angiography	Evaluate for pulmonary embolism, coronary anomalies	High suspicion for PE, unexplained cardiac symptoms
Upper GI Series/Endoscopy	Evaluate for GERD, esophagitis	Persistent symptoms consistent with GI etiology

Diagnostic Algorithm

A stepwise approach to diagnosing chest pain in children:

1. Initial risk stratification based on history and physical exam
2. Identify red flags for life-threatening conditions
3. Obtain ECG for any suspected cardiac etiology
4. Consider chest X-ray for respiratory symptoms or trauma
5. Laboratory studies based on clinical suspicion
6. Advanced imaging for select cases with concerning features
7. Consider psychosocial assessment for suspected psychogenic pain
8. Empiric treatment trial for likely diagnoses (e.g., GERD, costochondritis)

Management Strategies

General Approach to Management

Key principles in managing chest pain in children:

• Reassurance: Most pediatric chest pain is benign and self-limiting
• Education: Explain the likely cause and expected course
• Symptom management: Target the underlying cause
• Address anxiety: Recognize and manage associated anxiety in both child and parents
• Follow-up: Monitor for resolution or evolution of symptoms

Condition-Specific Management

Condition	Management Approach	Follow-up Recommendations
Musculoskeletal Pain (Costochondritis, Precordial Catch)	- Reassurance about benign nature - NSAIDs for pain and inflammation - Heat application - Activity modification if painful - Breathing exercises for precordial catch	- Follow-up in 2-4 weeks if persistent - Reevaluate if symptoms worsen or change - Consider physical therapy for recurrent cases
Asthma-Related Chest Pain	- Optimize asthma control - Bronchodilators for acute symptoms - Inhaled corticosteroids as indicated - Trigger avoidance - Consider pulmonary function testing	- Follow-up in 2-4 weeks to assess control - Adjust therapy based on symptom control - Consider pulmonology referral for difficult cases
Gastroesophageal Reflux	- Dietary modifications (avoid triggers) - Positional therapy (elevated head while sleeping) - H2 blockers or proton pump inhibitors - Avoidance of late meals - Weight management if applicable	- Trial of therapy for 2-4 weeks - Follow-up to assess response - Consider GI referral for refractory symptoms
Anxiety-Related Chest Pain	- Validate symptoms without reinforcement - Breathing exercises and relaxation techniques - Cognitive behavioral strategies - Identify and address stressors - Family-based interventions	- Follow-up in 2-4 weeks - Mental health referral for persistent symptoms - School intervention if school-related stressors
Myocarditis/Pericarditis	- Cardiology consultation - Activity restriction - Anti-inflammatory therapy - Monitoring for arrhythmias and heart failure - Hospitalization for moderate-severe cases	- Close cardiology follow-up - Serial echocardiograms - Gradual return to activity based on resolution
Pneumonia	- Appropriate antibiotics - Antipyretics for fever - Adequate hydration - Pain management for pleuritic pain - Respiratory support if needed	- Follow-up in 24-48 hours for severe cases - Repeat chest X-ray for complicated cases - Assess for complete resolution at 2-4 weeks

Pharmacological Management

Medication	Indications	Considerations
NSAIDs (Ibuprofen, Naproxen)	- Musculoskeletal pain - Inflammatory conditions - Mild pericarditis	- Short courses generally safe - Monitor for GI side effects - Use lowest effective dose - Avoid in certain cardiac conditions
Acetaminophen	- Mild pain of various etiologies - Alternative when NSAIDs contraindicated	- Generally safe, limited anti-inflammatory effect - Monitor total daily dose - May be less effective for inflammatory conditions
Proton Pump Inhibitors	- GERD-related chest pain - Esophagitis	- 2-4 week trial for diagnostic purposes - Longer courses require monitoring - Check for drug interactions
Bronchodilators	- Asthma-related chest pain - Reactive airway disease	- Use as needed for acute symptoms - Consider regular use if symptoms frequent - Monitor for cardiovascular side effects
Anxiolytics	- Severe anxiety with physical symptoms - Panic disorder	- Generally not first-line in children - Consider only with mental health involvement - Prefer cognitive-behavioral approaches

Non-Pharmacological Interventions

Intervention	Description	Evidence Level
Breathing Techniques	- Diaphragmatic breathing - Controlled breathing exercises - Breathing retraining	Moderate; helpful for anxiety, precordial catch, and hyperventilation
Heat/Cold Therapy	- Heating pad for musculoskeletal pain - Cold pack for acute inflammation - Alternating therapy	Low to moderate; based on clinical experience and patient preference
Cognitive Behavioral Techniques	- Pain coping strategies - Cognitive restructuring - Relaxation training	Moderate to high; effective for psychogenic and functional pain
Activity Modification	- Temporary restriction for cardiac conditions - Gradual return to activity - Modified exercise programs	Variable; depends on underlying condition
Dietary Interventions	- GERD management strategies - Elimination diets for suspected triggers - Meal timing modifications	Moderate; effective for GERD-related chest pain

Family Education and Support

• Explanation of diagnosis: Clear, age-appropriate information about the cause
• Natural history: Expected time course and resolution pattern
• Red flags: When to seek urgent medical attention
• Symptom management: Home-based strategies for comfort
• Psychological support: Addressing anxiety and catastrophizing

When to Refer

• Cardiology referral:
  • Exertional chest pain with concerning features
  • Abnormal cardiac examination or ECG
  • Family history of premature cardiac disease or sudden death
  • Chest pain with syncope or presyncope
• Pulmonology referral:
  • Recurrent respiratory symptoms
  • Poorly controlled asthma
  • Abnormal pulmonary function tests
• Gastroenterology referral:
  • Persistent symptoms despite empiric therapy
  • Alarm symptoms (weight loss, dysphagia, hematemesis)
  • Suspected esophageal motility disorder
• Mental health referral:
  • Significant anxiety or panic disorder
  • Functional symptoms affecting daily activities
  • Comorbid mental health conditions
• Emergency evaluation needed for:
  • Severe acute chest pain
  • Pain with dyspnea or hypoxemia
  • Chest pain with syncope
  • Chest trauma with respiratory compromise
  • Suspected pneumothorax or pulmonary embolism