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{{Peds top}} [[chest pain]]
{{PediatricPage|chest pain}}
==Background==
==Background==
*Common cause of presentation to the ED, especially in adolescents
*Common cause of presentation to the ED, especially in adolescents<ref>Jindal A, Singhi S. Acute chest pain. Indian J Pediatr. 2011 Oct;78(10):1262-7. PMID 21541647</ref>
*The majority of pediatric chest pain is benign and not cardiac in origin
*The vast majority (>95%) of pediatric chest pain is benign and non-cardiac in origin
*The main cause of cardiac chest pain in pediatrics is [[pericarditis]]
*Most common causes are musculoskeletal (costochondritis, muscle strain), idiopathic, and respiratory<ref>Huang SW, Liu YK. Pediatric Chest Pain: A Review of Diagnostic Tools in the Pediatric Emergency Department. Diagnostics (Basel). 2024 Mar 1;14(5). PMID 38473000</ref>
*Family history plays an important part screening for familial history of sudden death
*Cardiac causes are rare but must be identified: [[pericarditis]], [[myocarditis]], arrhythmias, coronary anomalies
*Family history plays an important part screening for familial history of sudden death, [[hypertrophic cardiomyopathy]], [[long QT syndrome]], or [[Marfan syndrome]]
 
===Red Flags for Cardiac Etiology===
*Exertional chest pain or syncope
*Associated palpitations, [[syncope]], or near-syncope
*History of [[Kawasaki disease]] (coronary aneurysms)
*Known congenital heart disease or cardiac surgery
*Family history of sudden cardiac death at age <50, [[hypertrophic cardiomyopathy|HCM]], [[long QT syndrome|LQTS]]
*Pain associated with fever (consider [[pericarditis]], [[myocarditis]])
*New murmur or abnormal cardiac exam
*[[Marfan syndrome]] habitus (consider aortic root dissection)


==Clinical Features==
==Clinical Features==
*[[Chest pain]]
===History===
*Physical exam
*Onset, location, duration, character, radiation, exertional vs. rest
**Listen for murmurs
*Reproducibility with palpation (suggests musculoskeletal)
**Palpate
*Associated symptoms: fever, dyspnea, palpitations, syncope, cough, anxiety
**Compress rib cage
*Recent illness, trauma, or strenuous activity
*Drug/substance use in adolescents (energy drinks, stimulants, vaping)
 
===Physical Exam===
*Vital signs including pulse oximetry
*Chest wall palpation for tenderness (reproducible tenderness suggests musculoskeletal cause)
*Cardiac auscultation: murmurs, rubs, gallops, muffled heart sounds
*Lung auscultation: wheezing, crackles, decreased breath sounds
*Assess for [[Marfan syndrome]] features: tall stature, arm span > height, arachnodactyly, pectus deformity


==Differential Diagnosis==
==Differential Diagnosis==
*Idiopathic (most common)
{{DDX CP peds}}
*Precordial catch syndrome
**Sudden, intense pain with deep inspiration, self-resolving
*Musculoskeletal
**[[Costochondritis]], [[thoracic trauma|trauma]]
*Pulmonary
**[[Pneumothorax]]
**[[Pneumonia (Peds)]]
**[[Pulmonary embolism]]
**[[Aortic dissection]]
***Uncommon but consider with history of [[connective tissue disease]]
*GI
**[[Esophagitis]]
**[[Esophageal spasm]]
**[[Gastritis]]
*Psychosomatic
**[[Panic attack]]
**[[Anxiety]]
*Cardiac (1%)
**Left-sided obstructive lesions
**[[Dysrhythmias]]
**[[HOCM]]
**[[Pericarditis]]
**[[Prinzmetal's angina]] (vasospasm)
**[[MI]]
***Rare, even post-[[Kawasaki]]
***Consider [[SCAD]]
**[[Mitral valve prolapse]]


==Evaluation==
==Evaluation==
*[[ECG]]
===Low Risk (Typical Musculoskeletal)===
*[[CXR]]
*Reproducible chest wall tenderness, no red flags
*Consider [[echocardiography]]
*No further workup generally needed
*Consider [[CXR]] if history of cough, fever, or dyspnea
 
===Moderate to High Risk===
*[[ECG]]: evaluate for ST changes, arrhythmia, prolonged QTc, ventricular hypertrophy, Brugada pattern
*[[CXR]]: cardiomegaly, pneumothorax, pneumonia, mediastinal widening
*[[Troponin]] if concern for [[myocarditis]] or pericarditis with myocardial involvement
*[[BNP]] or NT-proBNP if concern for heart failure
*Consider [[echocardiography]] for: new murmur, abnormal ECG, suspected pericardial effusion, known cardiac disease
*Consider CT angiography for suspected [[pulmonary embolism]] (rare in pediatrics, but consider in adolescents with risk factors)


==Management==
==Management==
===Musculoskeletal (Most Common)===
*Reassurance — this is the most important intervention
*NSAIDs ([[ibuprofen]]) for pain control
*Activity modification as needed
===Cardiac Causes===
*'''[[Pericarditis]]''': NSAIDs + [[colchicine]], cardiology consultation
*'''[[Myocarditis]]''': admit, cardiology, hemodynamic monitoring, avoid NSAIDs
*'''Arrhythmia''': see [[SVT (peds)]], [[ventricular tachycardia]]
*'''[[Pneumothorax]]''': see [[Pneumothorax]] management
*'''Aortic pathology''': emergent surgical consultation


==Disposition==
==Disposition==
===Admit===
*Hemodynamically unstable
*Suspected [[myocarditis]] or large pericardial effusion
*Significant arrhythmia
*[[Pneumothorax]] requiring intervention
===Discharge===
*Musculoskeletal chest pain with normal exam and no red flags
*Stable patients with mild pericarditis (arrange cardiology follow-up)
*Provide clear return precautions: worsening pain, exertional symptoms, syncope, palpitations, fever
*Cardiology referral for: abnormal ECG, family history of sudden death, exertional symptoms


==See Also==
==See Also==
*[[Chest pain]]
*[[Chest pain]]
*[[Acute chest pain]]
*[[Pericarditis]]
*[[Myocarditis]]
*[[Kawasaki disease]]


==External Links==
==External Links==

Revisión actual - 10:59 22 mar 2026

This page is for pediatric patients. For adult patients, see: chest pain

Background

  • Common cause of presentation to the ED, especially in adolescents[1]
  • The vast majority (>95%) of pediatric chest pain is benign and non-cardiac in origin
  • Most common causes are musculoskeletal (costochondritis, muscle strain), idiopathic, and respiratory[2]
  • Cardiac causes are rare but must be identified: pericarditis, myocarditis, arrhythmias, coronary anomalies
  • Family history plays an important part screening for familial history of sudden death, hypertrophic cardiomyopathy, long QT syndrome, or Marfan syndrome

Red Flags for Cardiac Etiology

  • Exertional chest pain or syncope
  • Associated palpitations, syncope, or near-syncope
  • History of Kawasaki disease (coronary aneurysms)
  • Known congenital heart disease or cardiac surgery
  • Family history of sudden cardiac death at age <50, HCM, LQTS
  • Pain associated with fever (consider pericarditis, myocarditis)
  • New murmur or abnormal cardiac exam
  • Marfan syndrome habitus (consider aortic root dissection)

Clinical Features

History

  • Onset, location, duration, character, radiation, exertional vs. rest
  • Reproducibility with palpation (suggests musculoskeletal)
  • Associated symptoms: fever, dyspnea, palpitations, syncope, cough, anxiety
  • Recent illness, trauma, or strenuous activity
  • Drug/substance use in adolescents (energy drinks, stimulants, vaping)

Physical Exam

  • Vital signs including pulse oximetry
  • Chest wall palpation for tenderness (reproducible tenderness suggests musculoskeletal cause)
  • Cardiac auscultation: murmurs, rubs, gallops, muffled heart sounds
  • Lung auscultation: wheezing, crackles, decreased breath sounds
  • Assess for Marfan syndrome features: tall stature, arm span > height, arachnodactyly, pectus deformity

Differential Diagnosis

Chest pain (peds)

Evaluation

Low Risk (Typical Musculoskeletal)

  • Reproducible chest wall tenderness, no red flags
  • No further workup generally needed
  • Consider CXR if history of cough, fever, or dyspnea

Moderate to High Risk

  • ECG: evaluate for ST changes, arrhythmia, prolonged QTc, ventricular hypertrophy, Brugada pattern
  • CXR: cardiomegaly, pneumothorax, pneumonia, mediastinal widening
  • Troponin if concern for myocarditis or pericarditis with myocardial involvement
  • BNP or NT-proBNP if concern for heart failure
  • Consider echocardiography for: new murmur, abnormal ECG, suspected pericardial effusion, known cardiac disease
  • Consider CT angiography for suspected pulmonary embolism (rare in pediatrics, but consider in adolescents with risk factors)

Management

Musculoskeletal (Most Common)

  • Reassurance — this is the most important intervention
  • NSAIDs (ibuprofen) for pain control
  • Activity modification as needed

Cardiac Causes

Disposition

Admit

  • Hemodynamically unstable
  • Suspected myocarditis or large pericardial effusion
  • Significant arrhythmia
  • Pneumothorax requiring intervention

Discharge

  • Musculoskeletal chest pain with normal exam and no red flags
  • Stable patients with mild pericarditis (arrange cardiology follow-up)
  • Provide clear return precautions: worsening pain, exertional symptoms, syncope, palpitations, fever
  • Cardiology referral for: abnormal ECG, family history of sudden death, exertional symptoms

See Also

External Links

References

  1. ↑ Jindal A, Singhi S. Acute chest pain. Indian J Pediatr. 2011 Oct;78(10):1262-7. PMID 21541647
  2. ↑ Huang SW, Liu YK. Pediatric Chest Pain: A Review of Diagnostic Tools in the Pediatric Emergency Department. Diagnostics (Basel). 2024 Mar 1;14(5). PMID 38473000
  3. ↑ Pickering D. Precordial catch syndrome. Arch Dis Child. 1981;56(5):401-403. doi:10.1136/adc.56.5.401
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